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Lord Mackie of Benshie: My Lords, can the noble Lord answer the simple question that I asked him? Do the Government still stand by the 1947 Act and by the statement of the Commission that in agriculture we deserve a standard of living comparable to that of others?

Lord Carter: My Lords, we certainly support the objective of Agenda 2000. But as I have said, that objective was set out in the 1947 Act and repealed by the previous government. Perhaps I may end with the remarks with which I concluded my maiden speech in this House nearly 12 years ago. I quoted A.G. Street. He once observed that for farmers everywhere in the world the most important and urgent question for them every day was not what the politicians would or would not do for them, but whether it would rain tomorrow.

6.4 p.m.

Lord Kimball: My Lords, I begin by congratulating my noble friend Lady Byford on her first speech from the Dispatch Box on her new portfolio. Those of us who are familiar with her husband's farm will realise that she comes from a very knowledgeable farming background. Perhaps I may also say what a pleasure it is to have the wind-up speech made by the noble Lord, Lord Carter. His knowledge of the subject is well known. It is very much appreciated by all of us that he has chosen to reply to this debate. We have had what I can only describe as an informed and sympathetic debate. I thank all noble Lords who have contributed to it and who have taken so much trouble to raise so many constructive points. With those few words, I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.

National Health Service

6.6 p.m.

Baroness Cumberlege rose to call attention to rising expectations and advances in medical science and their implications for the National Health Service over the next 50 years; and to move for Papers.

The noble Baroness said: My Lords, before I open this debate I would like to declare an interest. I am an executive director of a management consultancy firm called MJM Health-care Solutions. Ninety-five per cent. of our work is for and with the NHS.

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I love the NHS. I grew up in it. My father joined it as a GP in 1948. In my home we literally had blood on the carpet when patients came to the house in extremis. My father's surgery was in part of a converted boarding school for girls. It was reached by a rickety outside fire escape. In my village one had to be very fit to visit the doctor. It was heated by a paraffin stove and the icy temperature of my father's hands were legendary. It was said that he could make babies jump in the womb.

As children we were drip-fed with the importance of the NHS ethic based on the Christian principles of love thy neighbour and each according to his needs. My father's compassion, care, application and scientific knowledge brought home to us the reality of that ethic. He never spared himself or us if a patient was in need. It is a fine ethic and highly prized by the British people.

My concern and purpose in calling for this debate is not to "have a go" at the Government, although I know that the role of the Opposition is to oppose, question, seek to amend and refine. We shall do that later in the parliamentary year when the Government introduce their health Bill. But my purpose tonight is to debate with all sides of the House--I am very grateful to many of your Lordships who are taking part in it--how we can absorb modern technology, social change and people's aspirations while maintaining this much prized ethic, which we know so well, whether young, old, black, white, rich or poor or Prince William hit over the head with a golf club; the drunk in the gutter--all have a right to healthcare largely free at the point of delivery.

With infinite demand outstripping limited resources; with a service which is so popular but without a buoyant financial base to support it, quite simply tonight I ask this question: is the NHS sustainable and, if so, how? Successive governments, of course, have chipped away at the edges with prescription charges, charges for dentistry, eyesight tests and so on. Every government have recognised the value of lifting some of the burdens through occupational health schemes and through redrawing the boundaries between social care, which is means-tested, and healthcare, which is free. Every Government have sought to make the NHS accountable not only in clinical practice but in the use of resources. And every government since 1979 have increased the contribution from the taxpayer.

I do not wish to waste time bandying about figures, arguing which government in which year invested more resources in the NHS. I think that that is a barren debate since it inevitably gets into the territory of real growth, spinned growth and "double counting"--an art form in which I have to say this Government excel. Suffice to say that the average growth for the NHS over the past few years has been around 3 per cent. and future growth is likely to be roughly of the same order with inflationary pressures taken into account.

So I do not want to look back; I want to look forward. A new book published by the BMA and edited by Sir Michael Peckham and Marshall Marinker, was launched on 2nd December. It is entitled Clinical Futures. Its eight authors are among the most distinguished professors in the land. They argue that technological advances and the unravelling of the

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human genome will bring unparalleled opportunities for new treatments. My noble friend Lord Jenkin of Roding--no one could do it better than he--will address some of those issues. However, I wish to give two examples. The first concerns the remarkable developments in the field of brain repair and other parts of the nervous system. Cell transplants for Parkinson's Disease are already being tried experimentally and the authors predict that this field is likely to grow. There could be as many as 50,000 xenotransplants each year to remedy this awful condition. The authors also predict that by cloning sections of DNA genetic engineers will have the potential to produce designer babies, but only for those who can afford it.

This is heady stuff and your Lordships may have more sympathy for those suffering from Parkinson's Disease than for spoilt couples who wish to design their offspring. But that is so often the way things start.

Some noble Lords may remember Lord Trafford who was a Minister in your Lordships' House. Lord Trafford was a renal physician in Brighton. He and I worked together. He was a pioneer of renal dialysis. I remember going to his department and on his wall was a large "60". I asked him what it meant. He said that it meant two things. First, the 60 referred to the number of people he could take on dialysis; and if you were the 61st, that was very unfortunate, because you had to wait either for someone to die or for someone to have a successful transplant. The second reason that he had "60" on the wall was that he would not treat anyone over 60. You had to be under 60 to be treated. In Wales last week I related that to some specialist registrars--junior doctors about to become consultants. They were simply horrified because today we take access to renal dialysis as a matter of course.

The authors of this book are not fantasy merchants. They are not writers of fiction. They are people much respected by the medical and scientific community. They are predicting huge and expensive advances within the next few years. I have not mentioned life enhancing drugs and the pharmaceutical industry since I think my noble friends Lady Hooper and Lord Lyell may refer to them. The question I ask is how we are to absorb those costs if we are to improve the quality of the existing NHS--a much proclaimed aim of the Government--and still maintain its comprehensive nature. Within limited resources, if we improve quality we tend to jeopardise comprehensiveness. If we maintain comprehensiveness, we erode quality.

On Sunday night there was a news item on Radio 4 featuring a pioneering technique for cervical cytology. The Secretary of State said that if the Government's advisers recommended this new and expensive technique, money would be found. I applaud his confidence. But from where is the money to be found? Will it mean that people will have to wait even longer for routine surgery and treatment--a form of rationing well known to the NHS? My noble friend Lord McColl will address that issue and, after all, he is one who has an intimate knowledge of waiting lists. However, I simply point out that at the end of October 1,119,000 patients--that is still 35,000 patients more than the

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waiting list the Government inherited--are waiting for treatment. Ministers are rightly concerned that so many people should be waiting so long in pain and misery. Ministers have spent an extra £417 million on waiting lists this year. Over the past seven months the total list has fallen by almost 119,000. That works out at around £3,500 per patient. Normally the NHS expects to pay around £1,000 for each admission. So I should like to ask the Minister, the noble Baroness, Lady Hayman--I have given her notice of the question--why the Government pay unnecessarily twice or three times the going rate to achieve the outcome they wish.

I have also given the Minister notice of my second question. What has been happening to the number of patients suspended on waiting lists during the Government's waiting list initiative? A month by month table showing the national aggregate of suspensions as a percentage of list size would give a true picture. In the light of this Government's wish to be open and honest with the public, please could Ministers publish the full information and not be selective? We need to see the full picture not just the half the Government wish us to see.

I chose the title of the debate with great care. However, I had to alter my original proposal at the suggestion of the Officers of the House. My language apparently was not parliamentary, or at least was not suitable for a debate title. Originally I started with the proposal: to take note of 50 years of remarkable progress in healthcare. I wished to give recognition to those who over half a century had given their working lives to heal, comfort, and care for the sick. They have been, and are, remarkable men and women. I include not just doctors and nurses but managers, scientists, laboratory workers, paramedics, ward clerks, cooks, cleaners, porters, and so on. The vast majority show great commitment to the NHS and are prepared to give their best day in and day out. When non-executive directors are appointed--people from outside the service--they are universally surprised by the strong motivation of the workforce. But that should not be taken for granted. The title of the debate includes the words "rising expectations"--expectations not only of the public but also of those who work in the service. They expect to have sufficient resources to do the job well--not just money but sufficient colleagues and support staff. They expect the Government, ultimately their employer, to stand by them and support them. But the Government also have to look after the interests of the consumer. I understand why this Government are seeking greater clinical accountability through new--I have to say rather bureaucratic--mechanisms.

The National Institute for Clinical Excellence, the Commission for Health Improvement, clinical governance and so on are all tools for the future. They are heavyweight, some would say oppressive, tools with few incentives or rewards. In the light of the Bristol case, and some of the other high profile cases, I can understand the Government's concern. However, my concern is that while supporting greater accountability the Government should be aware of the very special relationship which exists between the doctor and his or her patient, between the public and the medical

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profession. If that trust is broken, if that special relationship is severed, we shall all be the losers--the public, the medical profession, the NHS and the Government.

I urge the Minister--I know that the noble Baroness is sympathetic and truly understands the NHS--to advocate with her ministerial colleagues a lighter touch and fewer occasions when we hear from the lips of her colleagues the words "heads will roll". Fear is only one way to manage an organisation and in my experience it is a pretty poor motivator. High quality recruits are the lifeblood of any organisation and retaining good staff is essential to its well being.

I wish to move now to the largest workforce within the NHS: nurses, midwives and health visitors. The noble Baroness, Lady McFarlane, will also mention the subject. The RCN constantly reminds us--it is right to do so--that nurses are the backbone of the NHS. They provide 80 per cent. of direct patient care. They spend more time with patients than any other professional group. So we should be very worried that 60 per cent. of employers report current and significant problems in recruiting nurses; that there is a shortage in excess of 8,000 full-time posts across the UK; and that the number of nurses aged over 55 is set to double over the next five years with a quarter of registered nurses in the NHS eligible for retirement in the year 2000. That is a very bleak picture, very bleak indeed. The NHS faces the worst shortage of nurses in a quarter of a century.

With an ever-increasing elderly population, the demands on the nursing workforce will not diminish; they will grow. Already we know that the quality of some elderly care is poor and the Government are seeking to improve that through tighter controls. But it will be fruitless to control a service which is already disappearing from view.

It was a much respected and loved Member of your Lordships' House, Lord Home, who, before he died, wrote:

    "To my deafness I'm accustomed, To my dentures I'm resigned, I can manage my bifocals But oh! how I miss my mind".
He was not alone. There are countless thousands who now and in the future share those fears. But their anxieties will deepen if there is not a committed nursing workforce with the skills, expertise and compassion to cope with the last years of life.

The Government are committed to organisational change and we shall be debating that in the months to come. This evening I have tried to address other challenges, longer-term challenges, which need to be thought through if we are to maintain the powerful and much-cherished ethic of the NHS: love thy neighbour and each according to his needs.

My Lords, I beg to move for Papers.

6.21 p.m.

Baroness Pitkeathley: My Lords, I am most grateful to the noble Baroness for giving us the opportunity to debate this important Motion this evening. The noble

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Baroness and I had an extremely productive relationship when she was a Minister and carers everywhere have reason to be grateful for her commitment to that cause.

Other noble Lords will address the scientific challenges which the noble Baroness put to us. I wish to look at matters from the patient angle and I am much more optimistic than the noble Baroness. It is a matter for rejoicing that we have higher expectations of the NHS than we have ever had before and that there is a great deal more focus on the patient than there was in the NHS's early days. However welcome it was 50 years ago, nobody could pretend that the NHS put the patient at its centre. We are now beginning to do that and that will have an effect on how we deal with some of the problems which the noble Baroness set out for us.

Too many people, especially older people, have been content with less than satisfactory healthcare because it is free and they grew up believing that healthcare had to be paid for. Linking that with our anxieties about the demographic time bomb and so many older people in our society means that old people are vulnerable to debates about rationing by age, one of which the noble Baroness brought to our attention.

But the development of the empowerment of the older people's movement and the empowerment of patients altogether, although it may have been slow to develop in this country, is gathering pace. Without any hesitation I should say that that is bound to have an effect on how we deal with patients in the future. It is a cause for celebration that that patient power movement is gathering pace.

That very fact makes us anxious about how we shall deal with the demands that such an empowered patient movement will put upon us. The problem in relation to the doomsday scenario as to how we shall cope with that is that we always view the future with the attitudes and statistics which are available to us now without taking account of the effect of changing attitudes and statistics and, above all, the effect of changing policies. For example, if we had been having this debate in 1951, we should have been in a scenario where the average length of stay in hospital was 45 days. Now it is less than seven days. The noble Baroness will remember during her time in office as a Minister the huge advances in the sophistication of anaesthetics which led to a great improvement in the quality and availability of day surgery, which had its own effect on how we could deal with the huge agenda before us.

The public health agenda undertaken by the Government, the reorganisation of primary care and the development of health action zones will surely have a huge and measurable effect on the health of our nation, as will the increased interest in health within schools, the workplace and neighbourhoods. Similarly, environmental issues--air and water quality and housing--will have an effect and will improve our health.

I wish to focus on a couple of special initiatives with which I have a connection as chairman of the New Opportunities Fund. They are not heavyweight and I certainly intend to ensure that they are not bureaucratic.

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The first of those is the development of healthy living centres. The Government have put aside £300 million for the development of healthy living centres, which are to focus on the wider determinants of health such as social exclusion, mental health, poor access to services and social and economic aspects of deprivation. We shall encourage innovative ways in which to respond to those challenges in order to meet the needs of different communities and groups. We may include projects which deal with community health services, health screening, physical activity, dietary advice, parenting classes, complementary therapy and anti-smoking projects. All of those will inevitably have a positive effect on the health of the community in which they operate.

We shall be inviting applications in early 1999. We intend to have at least 300 healthy living centres and will reach 20 per cent. of the population by the end of 2002.

A similarly important initiative which the New Opportunities Fund will undertake is in relation to cancer prevention, detection, treatment and care. We shall undertake neighbourhood projects which will increase the information available to patients. I am absolutely certain that that will bring about positive health outcomes. The cancer initiative will include how we deal with palliative care and also extremely strong links with the voluntary sector.

I am sure that the primary aim of healthy living centres and our cancer initiative to target people in communities who have the worst health and the greatest health inequalities will have an effect. We are well aware that we are undertaking a huge task, but my board is determined that we shall achieve positive results. I am confident that that, together with other initiatives which are being undertaken to promote health in our nation, will ensure that my optimism is justified in the future and that the NHS will not only continue to provide one of the best services in the world in relation to health but also will be more and more responsive to the needs of patients.

6.27 p.m.

Lord Addington: My Lords, when I looked at the title of the debate and saw that it referred to:

    "implications for the National Health Service over the next 50 years",
I was not sure at first that I should speak. Then I decided that there is one area of healthcare in particular which will become increasingly apparent over the next 50 years and which has not been dealt with in the past; that is, sports and exercise medicine.

What has been a rather Cinderella-like service in the past has now become something to which we are paying far more attention for the simple reason that more of us are playing sports. We are playing sports at a higher level and we are asking more of our bodies. Therefore, we are damaging them more frequently in the pursuit of a healthier lifestyle. If you run around, you will fall over and hurt yourself. If you walk slowly and sit in an armchair, you will not injure yourself.

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Bodies can be treated rather like cars. You can run them into the ground and let them fall apart or they can be allowed to rust quietly. The best approach is to use our bodies sensibly and to have the right sort of maintenance available.

The fact is that the NHS is not well suited to helping people in the area of sport and exercise; it was not designed to do so. The National Health Service was designed to stop people dying of x diseases. The great lie to modernisation is that we can only prepare for what happened yesterday and not for what may happen tomorrow. We did not know that there would be this great burst of people taking exercise. On previous occasions I have indulged myself in attacking the lycra culture of the sports industry, where people dance around and say, "Yes, you can be super fit"--and if not you can sit around in the right designer gear in the gymnasium smiling and hoping that your stomach does not start to sag when you walk over to sit on the next machine waiting for a photo opportunity.

That sort of culture seems to be breaking down now and people are beginning to realise that being fit takes graft. Our athletes at the top level are setting incredibly high standards. There is always a trickle-down effect in terms of performance in sport and exercise generally. We are now asking so much more of ourselves at amateur levels in sport.

I must declare an interest, although it is a declining one. I am an ageing rugby player. The nearest I have come to sports medicine was a rather bashed-up knuckle acquired in the parliamentary rugby team. It happened because for once I decided that I would not flatten somebody; I would merely grab him as he passed. He carried on going, and so did my finger. It is a minor injury of the kind that we do not generally take to doctors. Some injuries we will take to casualty--cuts or dislocations--and ask for treatment.

The fact is that people are taking time off work as a result of sports injuries and that has a national economic cost. It is something we must address. One way forward will be by training GPs to recognise the minor levels of rehabilitation and what is required. Every sportsman I have ever spoken to has a story about a GP telling them to rest for six weeks. If a person with a muscle out of place rests for six weeks, at the end of that time he will merely have a weakened muscle which will tear again. That is something about which every sportsman of my age knows.

We need a regular support service. Indeed, two British medical institutions--the National Sport and Medicine Institute and the British Association of Sport and Medicine--have put in place a diploma course for GPs to teach them how to deal with injuries, particularly at junior level. Within the medical establishment we need a Royal College for sports and exercise medicine. It is not just sportsmen who damage themselves; for example, ballet dancers sustain injury with appalling regularity, as do all dancers.

We need people who know about the problems, about the correct forms of rehabilitation and preparation. Unless that happens, our healthier society and the type of maintenance I mentioned earlier will not happen. We

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will continue to see far too many people suffering injuries, both big and small, and ultimately not returning to a healthier lifestyle.

I wish to make one point on a slightly different subject. With the growth in technology in medicine, as in all other parts of society, we are producing better equipment to do diagnostic work. That has one huge potential benefit for one small section of our society; that is, those who have difficulty in expressing themselves. It may be that they have intellectual impairment disabilities and do not have the means of making themselves understood easily to a doctor. I hope that, as the technology improves and comes on line, the Government will seek to encourage GPs to put those people forward for more scans. They will then be able to diagnose the problems. If a patient cannot make himself understood, he cannot tell the doctor what his nervous system is saying and therefore will not receive the right treatment. We have increasing means at our disposal to deal with that problem. I hope that both parts of my speech receive a favourable response.

6.34 p.m.

The Lord Bishop of Ely: My Lords, I am hesitant to add my lay voice to a subject which requires both the expertise and wisdom abundantly possessed by the noble Baroness, Lady Cumberlege, who introduced this welcome debate. In the 50th anniversary year of the NHS it is timely to ask whether the service can still do what it set out to do in 1948. I take seriously what the noble Baroness outlined by way of the difficulties the service will face. I am sorry that I am not speaking after the noble Lord, Lord Jenkin, who will say more on that subject. But I wish to indicate that I take those challenges very seriously.

The National Health Service seems to me to be the practical expression of a big idea. Indeed, it is sometimes said to be the only religious belief of the British people--an exaggeration, but not by much! The idea that the National Health Service embodies, as the noble Baroness said, is a moral one; that is, that it is a good thing when a human being in relievable distress is helped without regard to his or her capacity to pay for that help. That good is not just an individual good; it is a public good. And it is not a public good because that person may subsequently become a contributor to the national economy; he or she may not do so and it is still a public good. It is good for older people; good for people with severe disabilities and good because it is good for us all.

The interesting point about the NHS is that, having established this big idea in a massive institution, the mere existence of the institution teaches us the force of that idea. For all its difficulties, which one of us wants to return to inferior medicine for the poor? What is more, because it is a morally based institution, it attracts the services of men and women who inwardly believe that their life's purposes are best spent in serving it. There is a passion in such service; there is a passionate yes to relieving individual distress where it can be relieved without regard to that person's financial status or aspiration.

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But every institution, paradoxically, has to change in order to remain the same. An interesting article was published in the BMJ which reminds us how limited was the range of treatments available to general practitioners in the 1940s. To fulfil an analogous role in the modern world we have to take account of changes which are not merely medical, but also social. Those two require considerable thought.

If we ask what changes are imposed upon us, I would highlight, first, the matter of persisting inequalities. Those were demonstrated first by the Black Report of 1982 and, more recently, in September of this year in the Acheson Report on Inequalities in Health. That report makes abundantly clear that equity was one of the founding principles of the NHS and it still recommends that a way be found to ensure that healthcare services serving disadvantaged populations are not of poorer quality and less accessible. That is the same tone as was clear in 1948 when the NHS was founded.

Secondly, there is a complicated issue surrounding the matter of trust. Interpersonal public trust was a very different matter in 1948 than it is today. One of my deepest fears for the NHS is the attempt to embrace medical relationships within a contract culture in which everything is costed. If I am right, the moral idea at the heart of the NHS is that of kindness and compassion--as Blake put it, the human face divine of Mercy and Pity. In this idea there is an unspoken covenant between persons; a legal contract is an entirely different matter.

On a recent visit to Washington, I caught sight in the metro of an advertisement for a health scheme. There was a picture of a doctor examining a child and the caption read, "He is making a diagnosis, not a business decision". You would not compose a caption like that unless it addressed a real situation, and for me that situation--I am quite clear about it--is wholly undesirable. When a person gives blood for nothing, that is just kindness; but when the blood is turned into a product and legal dispute breaks out as to who owns it then the implicit covenant between people becomes qualitatively different.

I believe that we all have a role in protecting the NHS of the future from a litigiousness whose first instinct is suspicion and the presumption of bad faith. So modernisation is on everybody's lips, but what I want to hear from the moderniser's own lips is a commitment to the thought that the basic idea of the NHS is a moral one. There are those who in the modern world have actually no moral convictions whatever. They may be kindly people in their own way, but they believe that morality is simply a matter of personal opinion. There are those whose programmes of modernisation amount to covert ways of undermining the fundamental idea, and so there is very hard work for us all to do, making real the big idea in the structural, medical and administrative detail of a great institution which took to itself in 1948 the title "service".

6.41 p.m.

Lord Jenkin of Roding: My Lords, I am very grateful to my noble friend for introducing this debate and I should like to say how much I appreciated her

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splendid speech. Her Motion invites us to look ahead to the next 50 years and I should like to start by taking my text from an article in The Times this morning:

    "This therapy will be the medicine of the next century".
When one looks to see what "this therapy" is, it turns out to be a technique that would allow babies to be born with an embryonic "twin" to grow spare tissue and treat life-threatening diseases in later life. The imagination does not merely boggle: it is really very startled indeed. I shall come back to that in a few moments, but what I want to do is to try to glimpse what the future holds as regards the advance of science for the prevention and treatment of disease, together with the promotion of better health. I should like to start with a proposition which I heard about 10 years ago from that great doctor, Sir Christopher Booth, when we shared a platform at a conference in Paris. He said,

    "It is a popular view that science has unravelled the mysteries of human health and disease, with a few dark corners still to be uncovered. The truth is the precise opposite. There are a few areas where enlightenment prevails--but most of the rest is still shrouded in mystery".
I think we do well to remember that. The last 50 years, it is true, have seen huge advances: new imaging techniques, new diagnostic and screening methods, new treatments, new drugs--a proliferation of new drugs--new surgical techniques and much more. Of the next 50 years, one thing is absolutely certain: that is that the pace of scientific and technological advance will quicken. In the same way as much medical practice today is totally different from what it was 50 years ago, so we can be sure that by the year 2048--and I doubt whether many of us will be here--much, even most, medical practice will be different again.

The change, as my noble friend mentioned, is being driven, perhaps more than anything else, by the genetic revolution. I am no scientist, though I should declare an interest perhaps as the chairman of the Foundation for Science and Technology. As a non-scientist I have tried to understand what it is all about. I commend to my lay colleagues--and I am sure that the right reverend Prelate will be aware of this--a remarkable book called The Book of Man by Sir Walter Bodmer and Ian McKie, telling the story of the genetic revolution, from the generations of left-handed Kerrs on the Scottish Borders through to the human genome project, calling on the way on the Mendelian laws of inheritance and the double Helix of Watson and Crick.

In the Select Committee on Science and Technology's study of antibiotic resistance, we heard of the work to map the genomes of some of the dangerous pathogens that are becoming resistant to antibiotics and of the hope that this technique might lead to the discovery of the gene which promotes natural resistance. My first question to the Minister--like other speakers, I have given her notice--is: when are we going to see the Government's response to that report, which was published as long ago as last April?

The genetic revolution is prevailing over many areas of medicine and it so happened that the other day I was reading an issue of the New Scientist. In that one issue there were described a large number of new discoveries

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based on genetics. I have referred to the culturing of the human embryonic stem-cells, leading to ways of growing tissues or even organs for transplant. It is this work which, says today's Times, is the subject of a recommendation by the Human Fertilisation and Embryology Authority that the Government should widen the regulations to allow scientists to develop new therapies for diseased and damaged tissues. We seem to be moving along the road to cloning people.

My second question to the Minister is therefore this: are the Government satisfied that it is right that the committee of four experts who have drawn up this recommendation included nobody from the discipline of medical ethics? Is it sufficient to have the imprimatur of the main authority, which does include ethicists? Is that enough to make sure that the intentions of Parliament in this field are in fact being effectively implemented?

In that same issue of the New Scientist we also read of treating heart failure by gene therapy. And so it goes on: gene therapy to grow new teeth; DNA tests to show which drugs will or will not work; and so on. All this is in just one issue of a popular science journal.

How much more lies over the horizon? One has only to read the ABPI's recent publication, An A to Z of British Medicines Research, to see how many of the projects being researched by the drugs industry are based on genetics. One begins to appreciate, when one thinks in terms also of universities, research councils and medical charities, just how profound this revolution is going to be.

And so my last question--and with this I must sit down--is: are the institutions of medical education keeping up with all this? Are the doctors being trained in the new technology? Do continuing medical education and continuing professional development really fit the medical profession for this revolution--because without any doubt the revolution is profound?

6.47 p.m.

Baroness McFarlane of Llandaff: My Lords, I too would like to congratulate the noble Baroness, Lady Cumberlege, on initiating this debate and giving us the opportunity of discussing some profound issues. I might even compete with her on the issue of "blood on the carpet" in her childhood home. My father was a dentist and I can assure the noble Baroness that there was more blood on my carpet! That is a very powerful motivation, I think, for both of us in the view we take of the health service today.

The advances in medical science over the last 50 years are a cause for congratulation as regards the scientific community and the outcome of healthy partnerships between the biological sciences, medical applications and developments in medical technology. It seems sometimes that these advances are proceeding at an exponential rate and we cannot keep up with them. Other speakers have already mentioned the book published by the BMJ entitled Clinical Futures.

I was interested in the heading of the press release in relation to that book:

    "The blind may see and the deaf may hear, but society may become less tolerant".

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I think that is one of our fears: that we may tolerate handicap or imperfection less well than we have done in the past. But we applaud the improved quality of life enjoyed by those who have had, for instance, a heart by-pass operation or hip replacement or an infection treated with antibiotics. The relief is often palpable, and very often you can tell the relief from pain from the expression on a person's face. I should like to congratulate all who have been concerned in those advances.

I was told yesterday that information technology itself may well result in greater savings to the health service than medical science. We already see applications of information technology in services such as NHS Direct, which was launched by the Secretary of State last Friday at the Royal College of Nursing. It is a system of telephone triage, advice and referral given by nurses which can bring tremendous savings in the primary care services; but it also means that nurses have to learn new skills. I was going around in my old-fashioned way asking; "How do they advise a patient; how do they assess what is wrong unless they see the patient and unless they can touch the patient?" They have to learn new skills to do that.

It is right that we should pause from time to time and look at what these advances are doing to our National Health Service. In my early days I was taught that one of the major links in the whole National Health Service was the importance of prevention, health education and self-care. I think that the public may increasingly be looking to highly technological care and advances in medical science rather than looking to self-care--looking after ourselves and preventing ill health. I am glad to see that advances are being made in the healthy living centres which are being set up. We look forward to seeing what they will do. I am also glad to see that the public has an increasing recognition of the importance of healthy diet and exercise, even in the Palace of Westminster.

The second consideration that I wish to look at is what the advances in medical science do to other professions, particularly nursing. The noble Baroness dealt with that in wonderful detail. Over the years, I have seen nurses provide a convenient source of assistance to doctors in the conduct of medical research, in the administration and monitoring of complex drug regimes and in the use of medical equipment. As medical advances proceed so doctors tend to become busier and delegate some of their less-skilled tasks to nurses. In turn, the registered nurse becomes busy and delegates some of the caring aspects to the nursing assistant. But now hospital care is so complex and highly skilled that the kind of caring that people need in that setting requires complex knowledge and competency. I would be loath to see too much of the caring in those technological settings left to assistant nurses rather than registered nurses.

I am concerned because so often I hear, both from nurses and the public, the following question: "What has happened to the caring role of the nurse?" Indeed, that was the kind of remark that was fed into the survey of the Royal College of Nursing. The growing emphasis on specialist and technical skill was seen as risking

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alienating patients who hold great store by, "someone to be kind, to tell me what's going on, to be on my side and to hold my hand". I am sure that that is still an extremely important role for nurses in a situation where patients may be very frightened by what is happening to them. So I would commend that we give due care to what happens to the caring role of the nurse as the work of the profession increases in complexity.

6.54 p.m.

Baroness Perry of Southwark: My Lords, I should also like to congratulate my noble friend both on tabling the debate and on opening it with such a knowledgeable and moving speech. I am very pleased that the House is debating the issue this afternoon in such a sense of shared concern for the future of the NHS and its quality, without any political name-calling. Every government come into power with an ambition to improve the health of the nation and to preserve the NHS, of which we are all so justifiably proud. The ways in which these goals are met may differ from one government to another, but I hope that the Minister can acknowledge that the previous government worked hard to improve and protect the National Health Service, just as the present Government are also doing.

As one who is privileged to work in a community among scientific researchers, I should like to take my few minutes this afternoon to celebrate the advances in medical science which have taken place over the past 50 years and the research upon which they are based. Perhaps we should remind ourselves that health provision in the 1940s was largely in the hands of general practitioners. For most people, the family doctor was their major resource, and hospitals were places where you went only if you were very ill. The rising tide of expectation towards more sophisticated medical procedures was still little more than a ripple: most babies were born at home; infectious diseases like scarlet fever and whooping cough were a feature of the lives of children; diseases like tuberculosis and polio took a huge toll; cancer was still a word to be spoken in a whisper, as it carried an almost certain sentence of death; and people over the age of 70 were very old indeed. The childless remained childless unless they could adopt and, crucially, the diagnosis of disease still relied largely on the trained and experienced instincts of the general practitioner, who, with the best will in the world, inevitably sometimes got it wrong.

Today, all that has changed. Any symptom beyond a snuffly cold tends to find the patient subjected, sometimes willy-nilly, to a battery of hospital-based diagnostic tests involving the use of sophisticated and expensive technology. Diagnosis is so much more accurate and early, and thousands of lives are saved by the miracles of radiology, nuclear medicine, brain imaging, MRI, ultrasound and a host of other diagnostic techniques. That essential threshold of accurate diagnosis raises standards across medical practice beyond the wildest dreams of 50 years ago. One of the features of this diagnostic technology is the transparency of the results to the patient. Today, increased information about ourselves and our health is available to all of us as patients. But this is only the beginning.

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We have already seen transplant surgery become an every-day accepted part of life. Now we have developments in bio-technology, which seemed like science fiction only a decade ago, and, as other speakers have said, the cloning of human tissue is this week's new and lively issue. Yesterday, Professor Ron Laskey in Cambridge University announced a new method of identifying cells which are replicating abnormally--a breakthrough in cancer research of huge possibilities.

Indeed, these are things to celebrate. We should give thanks for the women and men of scientific discovery who, working in independent laboratories in universities or in commercial pharmaceutical companies, have provided us with the great leaps of knowledge that make our lives so much richer and our expectations of our own future and our children's future so joyfully abundant. But the funding for such research must continue. "Blue skies" research is the fundamental base upon which all other applied research depends and it will not be funded through private, profit-making companies. It is the responsibility of any civilised government to continue to put money into "blue skies" basic scientific research.

However, those developments, like the contents of Pandora's box, cannot be taken out or put back at will. Once they have been launched they form part of the expectations of an entire population. We cannot go on pretending that these expectations can be met by public money alone. There is already rationing in the National Health Service, and to a degree there has always been. Services provided in the public sector, just like goods provided by the private retail sector, are restricted by our ability to pay, whether as individuals or as a nation.

The health service already generously funds research at regional and national level which bears upon its immediate responsibilities. Could it not be persuaded to direct some of its research into looking at ways in which the service itself could be made more cost-effective, with a detached and long-term view of its future organisation, free of any immediate political imperatives? Perhaps a closer review could be made of the way in which GPs prescribe so readily to all their patients. The expectation that there must be a pill to cure everything from colds and flu to minor mood swings, is one which must be broken. I welcome the Government's emphasis on preventive medicine and on primary healthcare to keep as many people as possible out of the loop of expensive and secondary healthcare. That must be one of the ways ahead.

We value our National Health Service, and rightly so. It exists alongside superb private medicine and I believe that it should continue to do so. The health service is a priceless resource. It has served us magnificently for more than five decades and I have every confidence that it will continue to do so in the future. But all its advances depend on the continued achievement of scientific research, government-funded. The researchers of this country have done us proud so far and they deserve every support in the future.

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7 p.m.

Baroness Masham of Ilton: My Lords, I thank the noble Baroness, Lady Cumberledge, for initiating this debate.

Yesterday human spare-part cloning hit the headlines. Will the door be opened to human cloning in the next 50 years? Having seen so many complicated disabilities, one knows how important research is to alleviate serious illness and disease. The fast-developing biotechnology now seems to know no bounds. Scientists have progressed with cloning calves since Dolly the sheep. There is a concern that the development of medical technology has not been accompanied by morality. Life is becoming very complicated indeed.

During the past 50 years we have seen the wonderful development of antibiotics and how they have combated serious infection. But now we are experiencing drug-resistant strains of infection, which means that the superbugs are winning. With the scientific advancement of heart, liver and kidney replacements and the vulnerability of patients with suppressed immuno systems, basic hygiene should not be neglected.

It is difficult to imagine what may happen in the next 50 years, but the world is small and we should not be complacent about infection control. Drug-resistant tuberculosis has appeared in our modern society. Cases of TB are increasing. In the past 16 years we have seen HIV/AIDS appear and that has proved a challenge to the scientific and medical experts.

It is also a challenge to the pharmaceutical industry to find the correct drugs. It is a challenge to the health authorities to provide them. Sexually transmitted diseases such as gonorrhoea and herpes are increasing in many groups. Good health education is so essential.

There are so many fields of medicine which need researching, and the availability of the correct drugs can make a much better quality of life. It seems very unjust that someone with cancer or multiple sclerosis should have his drugs dictated by his postal code. I hope that this will be corrected.

It is most important that the pharmaceutical industry brings out more antibiotics and useful drugs, and that the drugs become available to all those people who will benefit from them. I hope that the Minister will agree that there should be more teaching in medical schools about the importance of prescribing correctly.

I ask the Minister what progress there is on screening for diabetes. Diabetes is a complicated condition and the number of cases is expected to double by the year 2010. Why is this? At the moment, about 123 million people world-wide suffer from diabetes. If diabetes is not detected it can cause strokes and heart disease. People need to know what to look out for and to be monitored.

As president of the Spinal Injuries Association, I should like some assurances from the Minister that people with spinal injuries who become paralysed will get the correct treatment in a spinal injuries unit. Over the past 50 years, this has not only been of great benefit to the patients but cost-effective to the health service. People who become paraplegic, if not treated correctly, can get many complications and cause unnecessary

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expense. If treated in a general ward without specially trained staff, patients are at risk of pressure-sores, sepsis, urinary infection, bowel problems and depression. General hospitals do not usually have the equipment needed. I hope that the Minister will ensure that the 11 UK spinal injury units providing specialist treatment and care receive the funding and support needed to continue their high quality service and improve on co-operation between agencies.

We hear much about a primary-led NHS. I am concerned that the new primary health groups are not fairly balanced. There will be seven GPs, no dentist, no pharmacist and only one lay person. The consumer representation is too weak. The doctors will be away from their patients and will have to find substitutes. With the complex matter of drugs and the cost involved, it is a pity that a pharmacist will not be a full member. If pharmacists are co-opted on to the groups, they will not have voting rights.

Let me end by asking the Minister what is to be the complaint procedure. We have seen the terrible cover-up of cases relating to doctors in Bristol. Having served on a Family Health Service Authority, I know that there can be problems involving doctors and dentists of negligence, alcohol abuse, drugs and sex. Will the doctors be self-regulatory or will an independent body do this work? I hope that the Government get it right as the good relationships between doctors and patients are very important. The public have high expectations of their doctors, but these can be easily damaged if doctors play God and patients feel let down.

7.6 p.m.

Baroness Hooper: My Lords, I, too, welcome this debate and my noble friend's initiative in tabling her Motion.

Earlier in the year we looked backwards to celebrate 50 years of an evolving, ever-changing National Health Service. It is changing because of the amazing and wonderful advances in our knowledge of science and technology; it is changing because of the very natural rises in people's expectation because of the increased information available to them, a point to which my noble friend Lady Perry referred. It is changing because I think we all now recognise that affordability is a factor and that there is not an unlimited pot of money available. So those who have to make difficult decisions on priorities--the Minister will be well aware of that--must be able to do so with the best possible information and data available in order to try to achieve that element of equity to which the right reverend Prelate referred.

These changes are not something which affect us and the National Health Service in isolation. Every country in the world is looking at its health service and seeking better and more comprehensive services within its means. Two weeks ago I was in Argentina, leading a trade mission supported by the Department of Trade and Industry which focused on healthcare. The interest there in how we managed things here made me realise, once again, how the National Health Service is regarded as a model. So we should be aware that what we do and what we plan to do is of interest not only to ourselves but to many others.

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Looking forward in the terms of the Motion before us, I believe that the prospect is very exciting. New frontiers are constantly being challenged, but we also have to exercise caution. Perhaps at this point I should declare an interest as a non-executive director of Smithkline Beecham. In the light of the merger announced today between Zeneca and Astra, perhaps I should say that the rationale behind many of the mega mergers of global pharmaceutical companies is the need to put more and more funding into research and development. There can of course be other synergies, but the cost of and the need for research and development are usually the main driver. Many, many millions of pounds go into exploring ways of making existing drugs more effective and treatment more appropriate as well as into researching new drugs. It is from this background that I should like to focus on advances in genetics. In doing so, I hope to complement what others, in particular my noble friend Lord Jenkin of Roding, have said.

I am not a scientist either but I can grasp that advances in genetics are allowing us to understand the molecular basis of disease. We are starting to be able to determine which genes are involved in quite complex diseases. This increased understanding is revolutionising the way medicines and other healthcare products--for example, diagnostics and vaccines--are being developed. Today, more and more pharmaceutical research and development is based on genetics. I accept that within probably a five to 10-year timeframe this new understanding will revolutionise the way medicines are delivered to patients. We are beginning to understand that any one disease can be made up of a cluster of different conditions which may respond to different medical interventions. In addition, we are beginning to understand why different individuals respond to drugs in different ways. If we are able to determine precisely how to give the right drug in the right dose to the right patient at the right time there will be huge benefits for the National Health Service, for patients, for the Government and for the industry too.

I therefore believe that the National Health Service needs to look at the implications of genetics for healthcare and healthcare delivery now in order to be able to ensure that patients in the United Kingdom reap the maximum benefits from this research when products start to come on line. They are a reality. I hope that the Minister will be able to reassure me in that respect.

When I did my stint as a Minister in the Department of Health I had responsibility for the international side. As I said at the outset of my remarks, the issues raised in this debate are not ones we should consider in isolation. So, apart from co-operation in medical education and research, there are also issues of intellectual property rights, patent protection and indeed ethical and moral considerations which must be dealt with fully and must be dealt with, I believe, at an international level, whether within the European Union, the Council of Europe or the World Health Organisation. I hope the Minister will be able to reassure me that the Government intend to play a full part in that.

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I wish the National Health Service another 50 years of vigorous life and growth and I trust that it will look outwards in doing so as well as forwards.

7.12 p.m.

Lord Rea: My Lords, the noble Baroness, Lady Cumberlege, has given us a very difficult task--six minutes to cover the next 50 years. I am aware that that is not the noble Baroness's fault. In fact this very tight timing, as it has turned out, was not necessary. I shall restrict my remarks to one aspect only: equity of access.

The National Health Service will try, as it always has, to make the best treatment available to all, regardless of social status or area of residence, a point made by the noble Baroness herself and by the right reverend Prelate the Bishop of Ely. Equity was one of the founding principles of the National Health Service. Of course it has not always been successful in achieving this, and middle class people and more affluent areas have managed to carve out a better service for themselves. That was encapsulated in 1972 by Dr. Julian Tudor Hart in The Inverse Care Law.

Things have certainly improved since then but there are still too many discrepancies in the standard of care between different regions and social groups. For instance, coronary bypass grafts and angioplasty are more frequently done in some health authorities than others--up to four times more frequently, I gather--and this variation is not at all related to the prevailing rates of coronary heart disease.

However, I am sure that my noble friend would agree that the overall "Healthier Nation" for which we are looking depends on the best practices being available across the country. Although the National Health Service is not the main determinant of mortality and morbidity rates, which have much wider determinants--I wish we had more time to discuss that point-- the National Health Service contributes hugely to the quality of people's lives. A top priority must be the achievement of equal access, not only to expensive high-tech interventions, which usually, but not always, affect a minority, but also to high quality primary and community care and well-staffed and efficient hospitals.

The Acheson report on Inequalities in Health, which we received two weeks ago, states on page 116:

    "An inverse care law is still evident in relation to the distribution of medical and nursing staff in relation to need. A number of studies have shown that deprived areas suffer increasing difficulties in recruiting general practitioners and this inequity extends beyond that of GPs to other primary care staff, including practice nurses, health visitors and district nurses".
My noble friend may care to outline how the changes in primary care which the Government propose will affect these questions of equity. It is a safe guess that more benefit to more people will come from bringing the best medical care that already exists in the National Health Service to all parts of the country and to all social and ethnic groups, than by expending very large sums on technical innovations which affect only a few.

However, this is not to deny that scientific advance is not only essential but also inevitable and highly desirable. As the noble Lord, Lord Jenkin, and the noble

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Baroness, Lady Masham, pointed out, we learn almost daily of new and exciting developments. But if, after proper assessment--and the Government's initiative in setting up the National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement (CHIMP) will help this evaluation--an innovation is found to be effective, particularly if it is cost-effective, it should rapidly be made available to all those in clinical need across the National Health Service. There will of course be strong pressure to favour those areas which can most effectively articulate their need--those who shout loudest--but I hope that my noble friend will be able to say that equity will reign and that strong efforts will be made to ensure that those with the greatest clinically measured need, even if they are suffering quietly, will come first.

Of course this will inevitably require increased resources--both achieving equity and accommodating technical progress--but this is right and proper as our GNP rises. In fact, we spend a lower proportion of our GNP on health than any other country at an equivalent economic level. It is worth pointing out that a proportion of scientific advances may actually save money by, for instance, avoiding hospital admissions, or enabling patients to continue working, or by avoiding more expensive forms of investigation or treatment. As new methods and technologies are to be brought in, there must be a culture that allows for the exit of forms of practice that have been shown to be unnecessary or ineffective. Some of these are costly in themselves.

Only this morning I read for the first time the book Clinical Futures. The chapter by Professor Peckham, who was the first director of R&D in the NHS, a post created in response to the report of your Lordships' Science and Technology Select Committee, is particularly relevant to tonight's debate and I commend it to the House. Six minutes is too short to attempt even a summary. But I should like to conclude with his words:

    "The future must be seen as an integration of scientific medicine within a broader framework that tackles social and other determinants of health. This is not an 'either or' choice but an absolute requirement if there is to be a balanced approach to health development".

7.20 p.m.

Lord Lyell: My Lords, once again, I am filling in as "tail-end Charlie". It has been a wonderful and stimulating debate. I am immensely grateful to my noble friend Lady Cumberlege for giving us the opportunity to consider the achievements of the National Health Service over the past 50 years and its future prospects.

In opening, my noble friend was kind enough to refer to my noble friend Lady Hooper who sits behind me. However, I heard her also refer to me as "Lady Lyell". I know that there are three others and that miracles occur, but not necessarily in six minutes in your Lordships' House!

My noble friend may remember that in a previous incarnation she asked me to read research material more thoroughly and not to muddle appetite-depressants with contraceptives. She said that I, as a bachelor, might have thought that they were the same. I do not! As I have

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said, I am immensely grateful to my noble friend for giving us this opportunity to look at what she calls the "rising expectations" for the National Health Service over the next 50 years.

In 1948, I was nine years old. I remember being at school where I contracted a disease known as glandular fever. I was told that I was wet, gutless and would be unable to play football or do all the other things which the Ministers' sons do. I managed to come through that.

I am delighted to see that the noble Lord, Lord Addington, is back in his place. Forty years ago, I achieved a spectacular own goal in a town well known to my noble friend Lord Astor. I am delighted to see him joining us on the Front Bench again. I went skiing in a town called Davos and suffered a triple fracture of the leg. The next morning I had immediate surgery. However, something called "complications" arose. I await comments on that from my noble friend Lord McColl of Dulwich, if he has the time. I spent five weeks in Davos Hospital and a further five months in plaster. There were further complications and I spent another three months in plaster in 1960, followed by six weeks in hospital. That was a self-inflicted injury. I have also broken hands, an ankle, and have dislocated my shoulders when skiing. However, all that pales into insignificance, as always in your Lordships' House, when compared with the sheer guts and courage, if I may call it that, of the noble Baroness, Lady Masham of Ilton. We extend to her our admiration. We are delighted that she is speaking in this debate. Following the appalling injuries that she suffered in, I think, 1958 or 1959, she is now just a little slower than normal.

One can have self-inflicted orthopaedic injuries, but I am thinking also of what I call the "self-inflicted injuries of over-indulgence in a normal lifestyle", perhaps in your Lordships' House. I am a Scot and an accountant. I have two remedies. One is called a weighing machine or bathroom scales. The second is the waistband of my trousers. Although I am a Scot, I am not wearing a kilt! Incidentally, I enjoyed the description by the noble Lord, Lord Addington, of the body contours of people wearing leisure suits. My noble friend Lord Astor and I will remember that when the Lords and Commons Ski Club goes out on the second Friday of January to challenge our Swiss friends on a terrifyingly fast giant slalom slope. The noble Lord, Lord Addington, is right, but we lack nothing in application!

How can we get round the problems of self-inflicted injuries in normal lifestyle? I took some advice from the pharmaceutical industry this morning. The noble Baroness, Lady Pitkeathley, quoted some interesting figures about occupation and length of stay in hospital, thus saving me 20 seconds of my time because I shall not have to repeat that. I was fascinated to learn that, according to the OECD medical report, the cost of medicines per head in the United Kingdom is about £86 per year. The comparative figure in Japan is £277. I wonder what the Japanese get up to or what they are gulping down. The figure for France is over £200. According to the OECD, the only nation with a figure lower than ours is the Republic of Ireland, at £77. I call that the "PTAD syndrome". In Ireland it is known as being "partial to a drop". Your Lordships can discuss

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the liquid! However, there must be something in the lifestyle of everybody in Ireland to account for that figure. I do not understand why, but that is some indication of what medicines can do for your Lordships and for everybody in terms of saving the NHS the cost of hospital treatments.

I was absolutely "stunned"--I hope that that is a reasonable word to use--by the speech of my noble friend Lord Jenkin of Roding, which was excellent, even by his own standards. He expressed perfectly what I think is the path of the National Health Service and, indeed, the pharmaceutical industry over the next 50 years. I enjoyed my noble friend's comments about the left-handed cars, but I think that he spells it "Kerr". He will be aware that if my right honourable friend, who calls himself "Ancram", did not have that name, he would be a Kerr. In view of the events of the past week, perhaps he may care to repeat that--certainly, I would.

My noble friend Lady Hooper referred to a massive merger which has been reported today. I understand that the revenues of the two combined companies will be in the region of 14 billion dollars. That compares with a figure of 35 billion dollars for the largest United States company. The same report in the Financial Times advises that the cost of creating what it calls a "blockbuster" drug is 500 million dollars. That compares with the possible revenues, if you get it right, of 1 billion dollars. Those are the figures with which the industry, which is so well represented by my noble friend, is dealing. My noble friend Lord Jenkin of Roding also referred to the prospects of that industry in terms of science and reviews. I hope that on a future occasion I shall be able to discuss the pharmaceutical industry and its costs, let alone all the pills. I thank my noble friend Lady Cumberlege for giving us this opportunity.

7.25 p.m.

Lord Clement-Jones: My Lords, I add the thanks of these Benches to the noble Baroness, Lady Cumberlege, for initiating this debate and for the typically thoughtful spirit in which she introduced it.

This has been a fascinating debate, covering a broad range of scientific, moral, ethical, medical and, indeed, commercial points. The only slightly worrying part of the debate was when the noble Lord, Lord Lyell, looked directly at me when talking about "over-indulgence" in this House. I wondered whether he had discovered some awful secret.

Clearly, one of the required pieces of reading for this debate has been the BMA's book, Clinical Futures. Some of those medical scenarios fill me with considerable optimism: the fact that genetics and genome research will open up so many opportunities for new treatments and for identifying risk factors; the new scanning techniques which could allow instant diagnosis; and the dramatic improvement in the monitoring of health indicators.

On the other hand, other aspects fill me with gloom. I refer to the fact that because of our ability to "genetically select", we could have less tolerance of those born with disabilities; passive entertainment will

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enhance risk factors for heart disease and osteoporosis; and we shall rely on drugs rather than on a change in lifestyle to counter such risks. All those aspects carry major implications for the health service in the next century.

To those factors we can add a number of other challenges for the NHS which have already emerged, such as increased life expectancy; a shift in emphasis from life-saving treatments to treatments which improve the quality of life--many of them relatively expensive; and a move towards more preventive medicine and even possibly a re-emergence of infectious diseases. As a result of the recent report of the Human Fertilisation and Embryology Authority, to which many noble Lords have referred, we now have in prospect what could amount to the manufacture of human spare parts or "cell nucleus replacement", as I have no doubt that we should learn to call it.

Above all, we are moving into an era of greater consumer demands, from what Professor Rudolph Klein has called the "church" model--a paternalist system, driven by doctors where solely they determine what treatment is received--to the "garage" model, where the consumer takes his or her body in for repair and retains control over what happens to it. The desire--indeed, demand--for more information is a key part of that movement. Patients now have the ability to access information from helplines and the Internet in a way they never had before, which in itself provides a challenge to clinicians, particularly when some of that information is of poor quality.

Those are issues which the Government need to take on board now. The future is already with us. My honourable friend Mr. Simon Hughes, in the debate on the Queen's Speech in the other place, described the key problems of the NHS today as being those of the new three Rs: rationing, recruitment and resources.

I want to take the opportunity today to talk about two of those three. Our healthcare spending at 6.9 per cent. of GDP is lower than that of a great many European countries where the average is 7.7 per cent., but we have the best value health service, as a proportion of GDP, in the world, and we should be prepared to pay more for it. However, there are no great new sources of income. Hypothecated tobacco taxes, as suggested by my party, would make a useful addition to NHS revenue, but would not make a dramatic difference.

Levying charges for health services has been a perennial suggestion ever since the health service was formed. The new road traffic (NHS charges) Act is an attempt to claw back some income for hospital trusts other than through taxation. But there must be a limit to this process. My party rejects any move to hotel-type charges or charges for seeing general practitioners. We believe that the universality of the health service must be retained. Just to stand still, however, the NHS needs a real income increase of at least 3 per cent. a year. At the end of the day, whatever taxation policy is adopted and whatever additional money the Department of Health manages to wring out of the Treasury, we have to accept that there will always be rationing at the edges.

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As new developments emerge, there will never be enough money to fund every treatment or test or procedure.

As anyone knows who is close to the health service, whether as professional or patient, rationing decisions are being taken every day of the week. Many noble Lords have mentioned that. However, government Ministers claim that that does not happen. The Conservatives, after 18 years of denial when in government, have finally acknowledged the problem now they are in opposition. Miss Widdecombe has ironically called for a mature debate on the subject. The Government, on the other hand, believe that problems will not arise if we set up enough new bodies--such as NICE and the commission for health improvement--to ensure that new treatments are clinically effective. We should put our faith in what is called evidence based medicine and the necessary resources will be found. That was very much the tenor of the previous government's response to the 1995 Commons Health Select Committee which called for a new national framework.

However, we on these Benches believe that we have to acknowledge and tackle the problem. We need to understand what people's expectations are and what responsibilities they and the NHS have. As Professor Klein says, the fact that no patient under the current system has a legal right to specific treatment means that the clinician decides what the patient needs and political problems are in effect converted into clinical problems. It is time that politicians grasped the nettle.

The NHS is currently one of our best loved institutions. There is still a high degree of trust. Recent developments, however, whether it is the publicity surrounding new so-called lifestyle drugs such as Xenical and Viagra, or cancer patients being unable to get access to a number of treatments involving Taxol and Taxotere which can prolong life for up to 14 months, or the fact that schizophrenia patients are unable to obtain Clozapine and other atypical anti-psychotic drugs, have all highlighted the rationing issue. Postcode rationing is no longer a surprise but a fact of life.

Above all, it is cases like that of Child B, Jaymee Bowen, described in the recent study by Chris Ham for the King's Fund, which starkly illustrate the need for a properly informed public debate leading to public and transparent policies. We cannot just muddle through relying on the occasional blustering edict from the Secretary of State. It is becoming increasingly obvious to the public that if the Government have ruled out increased taxation, not all treatments can be funded. They perceive that rationing is taking place.

If the basis of that rationing is not made clear, trust in the NHS will inevitably be eroded. Polls have made it clear that there is already a level of cynicism with regard to the NHS, its ability to deliver services in the way that it has to date, and even its ability to survive the next 50 years. We need to make sure that new clinical developments are seen as an opportunity for the NHS, not as a threat.

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I know about the kinds of clinical decisions that have to be made. My late wife fought a battle for five years with ovarian cancer. She was also a doctor and one of the lucky ones. In those days, the late 80s, because hospital consultants took the rationing decisions, she was able to take advantage of every new treatment as it came along in case it provided a long-term cure. In the time that she was kept alive she founded CancerBACUP which since then has helped hundreds of thousands of cancer patients with information and support. That was 1987, before the health service reforms of 1991. I wonder what would happen now. As we speak, on cost grounds cancer patients are being denied the drugs that would certainly prolong their lives. Whatever decisions are made, they should be transparent and they should be taken with the fullest public knowledge and consent. We need to get the balance right between individual clinical discretion and national priorities.

We on these Benches propose a national standing conference. However, its role would not be to determine a core package of healthcare to be available. The key role of such a standing conference should, I believe, be advisory and not prescriptive. Its role would be to establish a clear set of values and guidelines to clarify the decision making process which would then be applied by local health authorities, trusts and GPs in order to ensure that patients are entitled to equal and consistent treatment; and to ensure that they are given clear treatment options and proper reasons where treatment is denied by the decision makers themselves, and long-term counselling for families affected by decisions not to treat. It is not a question of precisely which services are provided, but how decisions are made and who takes them.

A new NHS charter could be part of this equation. We should give proper consideration to the report of Greg Dykes--for whom I have a considerable regard--but any priorities or charter decided by the standing conference must have legitimacy. It cannot just be drawn up by one man, however able. No rationing solution is ideal, but I hope that the Government will take the opportunity to acknowledge and to tackle the issue in the new modernisation of the NHS Bill.

7.35 p.m.

Lord McColl of Dulwich: My Lords, I, too, wish to thank the noble Baroness, Lady Cumberlege, for drawing our attention to this important subject. In considering the rising expectations and advances in medical science and how they will impact on the NHS over the next 50 years, I would like to discuss two serious issues which have surfaced recently and which threaten those rising expectations.

The first involves some worrying developments in the postgraduate training of doctors. If this training is undermined, the NHS clearly will be in jeopardy. As I am sure noble Lords are aware, the average age at which doctors qualify in this country is about 24. If they wish to specialise in hospital work, they then embark on a 10 to 17 years' training programme before they are appointed consultants. If they fail to secure a consultant post after this period of time, there is nowhere for them to go in this country because we have this huge

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monopoly employer, the National Health Service. They either have to leave medicine or to start training in some other speciality. That, again, may take many years.

I am not suggesting for a moment that everyone who trains to be a consultant should automatically secure such a post, but there has to be a sensible relationship between the number we train and the number of vacancies that will be available at the end of their training. In a debate in your Lordships' House last week the noble Lord, Lord Winston, drew attention to the plight of trainees in obstetrics and gynaecology where far too many have been trained and the number of consultant posts has been reduced. There soon may be as many as 200 fully trained personnel waiting for consultant posts with little hope of ever achieving that status.

The present junior staff training scheme was devised by Sir Kenneth Calman and should have been implemented many years ago. In criticising the present state of affairs I am well aware that it is easy to criticise and to make speeches about a subject without doing anything to help. I would like to point out that the present training scheme was based on a surgical training scheme which I introduced into the south-east region in 1972 which ran for 15 years. It was based on the principle which was later adopted by Sir Kenneth Calman whereby trainees were taken in for complete training. They were given the security of knowing that they could stay in the programme until they were fully trained provided their progress was satisfactory. Half the time was spent in district general hospitals, half in teaching hospitals, with the possibility of a year abroad. The idea was to enable the trainees to do all their training from one centre so that their families could settle in one district and not have to move around the country. This greatly improved the quality of life of the trainees. In order not to train too many consultants for the number of posts available, half the trainees were from the Commonwealth and returned to their own countries at the end of the training programme. The other cardinal feature was that no new trainees were taken on until those at the top had found permanent employment, provided that their progress was satisfactory and that they were making a serious attempt to secure a consultant post.

A major defect in the present programme is that when the trainees come to the end of their training they are replaced by new trainees, who start at the beginning. As we are dealing with a monopoly employer, there is nowhere for those trainees to go. It is clearly an unsatisfactory state of affairs. I do not seek to blame anyone; I certainly do not blame the Government. However, the question arises as to who authorises the advertisements for the new posts. I suspect that it is the postgraduate deans who are ultimately responsible. Whoever it is, will the Government encourage them to stop advertising for new trainees and simply continue to employ the present trainees until they secure permanent appointments? It seems obvious, does it not?

Furthermore, will the Government give urgent attention to increasing the number of consultant posts in obstetrics and gynaecology to restore them to their previous number? There has been a cut in the number

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of consultants over the past year or two. The Government are to make available some £20 billion of extra money. Could some of it be used to create more consultant posts, as originally planned? Apart from that being a reasonable and humane solution to a major problem, it might also save the NHS many hundreds of millions of pounds in huge legal settlements made by the courts as a result of alleged mistakes in medical practice, which are made more common by gross under-staffing. There are fewer consultants per head of population in this country than in any other European country. We desperately need to create more consultant posts. I hope that the Government will reverse the cuts that have occurred over the past year in the creation of new posts. We owe it to patients, junior medical staff and medical students.

In this country we are very fortunate in the quality of the younger generation in medicine. Their academic standards, professional expertise, kindness and service to patients is better than it has ever been. And their sense of humour is as good as ever. A professor of forensic medicine was lecturing students on homicide and gunshot wounds when he suddenly mentioned that he was worried about becoming senile. He said that he had an agreement with his wife, also a forensic expert, that she would arrange a shotgun accident to carry him off if she saw any signs of senility in him. A student at the back of the lecture theatre shouted out: "Left it a bit a late, hasn't she?".

The second subject to which I wish to draw the attention of the House is the way in which morale is being undermined by an obsession with reducing the numbers on waiting lists. For 20 years the Labour Party campaigned to discredit previous Conservative governments over their handling of the NHS, pretending that they were privatising it, destroying it and greatly increasing the number of people on the waiting lists. They set great store by their claim that they would reduce waiting lists. Unfortunately, last year the lists started to rise dramatically, so they began a campaign to reduce them again.

It is an interesting campaign. It consists of a number of fiddles. The first is to transfer patients from the main waiting lists to subsidiary waiting lists which do not appear in official returns to the Department of Health. Therefore those patients do not appear in the waiting list statistics. That little game began in June 1998, interestingly at exactly the same time as there seemed to be a reduction in the waiting lists. Bradford Hospital NHS Trust has been told that orthopaedic patients waiting for the removal of internal fixations (pieces of metal and so on) are to be included on a new list and that that is not to be included in the official waiting list statistics.

The second fiddle is to have waiting lists for the waiting lists. There are increasing delays for patients simply to have their name put on a waiting list. That slows the rates down, hence making it appear that there is a reduction. Some consultants are holding fewer clinics, so fewer patients are being seen to be placed on

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a waiting list. Frenchay Healthcare Trust has almost a two-year wait for an appointment to see an orthopaedic surgeon.

The third fiddle is that some patients are being denied operations altogether: for varicose veins, sebaceous cysts and lipomas. The people of Bermondsey are very angry that they are having to pay hundreds of pounds for operations to be done privately which until recently were available on the NHS. Will the Government put that matter right?

The fourth fiddle is to encourage simple procedures being carried out ahead of more serious ones, thus reducing the numbers on the waiting list. It means that those with serious conditions wait longer. The Government's own figures show that the list of those who waited more than 12 months has more than doubled, from 31,000 to 63,000. One of the great contributions that Virginia Bottomley made to the NHS was radically to reduce to under a year the waiting time for almost all patients. She ought to receive credit for that.

The fifth fiddle is an aggressively repeated inquiry as to whether a patient still requires treatment. It includes a new method of including targets for a number of patients to be removed from lists.

These techniques are not good for patients. They undermine morale. They are not good for the caring professions. It is an extraordinarily demoralising exercise. Could the Government see their way to admitting that perhaps they have indulged in a little propaganda over the past 20 years? Will they admit their mistake and try to put matters right, and stop the fiddles?

These problems are pertinent to rising expectations for the future of the NHS. I have never really considered the main problem of the NHS to be a shortage of money. The major problem is one of decline in morale, not only among those who work in the NHS but also among patients.

7.47 p.m.

Baroness Hayman: My Lords, I am grateful to the noble Baroness for introducing what has been a fascinating debate. Perhaps I may respond to the tenor of the majority of comments rather than that of the contribution of the noble Lord, Lord McColl. I am afraid the noble Lord repeated allegations and slurs that are completely untrue regarding this Government's record in terms of finally turning the tide of rising waiting lists that we inherited.

Without going through each point of the noble Lord's remarks, I can tell him that there has been no change whatever in the basis on which statistics are collected. That has been made absolutely clear in correspondence. I was particularly upset to hear the noble Lord repeat the allegation against Bradford Hospitals NHS Trust. It has caused great concern to the staff working there. The chairman of that trust specifically wrote to the Leader of the Opposition, Mr. Hague, asking him not to repeat allegations that the figures were being fiddled in any way.

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I do not want to take up too much of your Lordships' time dealing with what tend to be party-political points in a debate that has been far more wide-ranging.

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