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Lord Burlison: My Lords, perhaps I may remind the noble Baroness that this is a timed debate and that she has exceeded her time.

Baroness Sharp of Guildford: My Lords, I am finishing. We need to explore different initiatives and we need to go forward from here.

4.31 p.m.

Lord Forsyth of Drumlean: My Lords, in listening to the debate, I find myself in an extraordinary position. I congratulate my noble friend Lady Cumberlege for initiating it because not only has she given us an opportunity to discuss this matter at a topical time--she delivered a splendid speech, if I may say so, summarising the position and drawing on her considerable experience--but I believe she may have given the Minister and the Government a window of opportunity. Listening to the debate and the speeches, it is quite clear that the view, certainly in this House, as in the country, is that the game is up. The days of pretending that it is possible to have the kind of health service that our people are entitled to and, at the same time, pledging no tax increases, are at an end unless other sources of funding to meet the needs of the health service are being suggested.

The Government, through the discussions which take place in the Budget, are effectively setting a ceiling on the quality and quantity of healthcare that people may have in this country, and are also preventing alternative providers from providing competition to the health service and thereby improving quality. At the end of the debate the Minister should say that two things have changed. He should say, "We are going to stop claiming that we can have the health service that we all believe that we need and to which our people are entitled without finding additional resources"; and he should say also, "We shall stop going around saying that we have the best health service in the world".

If we are talking about the people in the health service--the doctors, the nurses and all the others--I am prepared to accept that we may very well have the best health service in the world. But if we are talking about the resources and the range of treatments available to patients, it is no longer the case. A number of suggestions have been made in the debate for additional sources of revenue.

Can we please end this partisan, political point scoring of whose statistics on the health service were better; who spent more money; who did what. The truth is that we all tried to do what we could for the health service--we have all seen the budget increasing--but we have all shied away from ideas such as hypothecation and insurance. If the Tories

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stand up and say, "Insurance", the Labour Party stands up and says, "Private insurance is privatisation. They want to destroy the health service", whereas the truth is that you can have mutually funded insurance schemes and privately funded health insurance schemes. As my noble friend Lord Crickhowell indicated, such schemes need to be looked at.

I have been surprised by some of the figures I have seen in articles in the press--mainly driven by the excellent work carried out by Dr. David Green of the Institute of Economic Affairs--on comparisons with other countries in Europe. For example, he has estimated that if we were to match the percentage of the GDP spent on health by Germany, we would have to spend an extra £30 billion. That would mean--assuming no reduction in yield--an increase in the basic rate of tax of nearly 12 pence. Not even the Prime Minister, Mr. Blair, can deliver that kind of additional resource without contemplating that kind of increase in tax.

My noble friend Lord Biffen said that it may not be necessary to increase spending by that amount, but, as the noble Baroness, Lady Sharp, pointed out, we need to look at the outcomes in these countries and compare them with the outcomes in this country to see the extent to which our people are being cheated. A British person is twice as likely to die from heart disease as his neighbours across the Channel. That is not all down to diet. Lung cancer patients in Germany have twice the five-year survival rate as patients in Britain. Women with ovarian cancer have a 30 per cent chance of surviving for five years in the United Kingdom; in Sweden it is 45 per cent. Other countries in Europe, such as France and Germany--and some of them have pretty socialist governments--do not find it necessary to have the state running the hospitals, employing all the nurses, employing all the doctors and funding all their healthcare out of taxes. Is it just possible that we might be out of step with the others and that we might learn from their experience?

The Government will claim that they are spending more--as indeed they are--but they are also introducing rationing. For the first time the drugs budget in the NHS is cash limited. I have a brief from Central Office but I am not going to read out any of the examples. We all read the newspapers; we know that people are not getting the cancer drugs they need; we know that there is postcode rationing. I do the Minister the courtesy of acknowledging that he would not wish it to be the case, but it is the case that we have rationing and it is the case that the Government's organisation--paradoxically called NICE--has a brief to take that forward on an institutionalised basis.

One of the things that I miss about being in this House rather than in the other place is the constituency post. I made some enquiries about the constituency post of someone I trust implicitly--my wife. She has been a House of Commons secretary for 20 years; 14 years with me. She tells me that she has never seen a constituency post on the health service such as is coming in now: tales of people on trolleys; tales of people in difficulty. I know that every January is the

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same: there is always a crisis in the health service. It was the same under the previous government; it is the same under this Government. The reason for the crisis is that we are not able to staff for the peaks of demand. Whatever speeches are made, whatever inquiries are made, whatever initiatives are taken by the Government, I can guarantee that next January there will be another crisis in the health service. There is a crisis of manpower and funding which needs to be urgently addressed.

Insurance schemes could add resources. The withdrawal of the tax relief on private insurance has resulted in a quarter of a million people cancelling their policies. That is a quarter of a million people--whose medical care will have to be funded out of an over-stretched budget--who would otherwise have added to the resources of the health service as a whole. There is a philosophical question here. Surely as people get wealthier they should be asked to make more of a contribution towards their health care. They certainly should not be prevented from doing so, which appears to be the prevalent view in certain quarters.

We do not have to have a service which depends on staff being overstretched and overworked. In this day and age, it is ridiculous that we rely on doctors who work 60 and 70 hours a week to carry out their tasks.

Finally, I do not know how he does it, but the Prime Minister seems to lead a charmed life. He is standing high in the opinion polls; he is respected in the country; and he was elected on a platform to do something about the health service. He is uniquely placed now to take action on the funding of the service, to set up a commission to look at the funding and to try to proceed on an all-party basis. His administration will then be remembered as one that did something of real worth for our country.

4.39 p.m.

Baroness McIntosh of Hudnall: My Lords, I join other noble Lords in thanking the noble Baroness, Lady Cumberlege, for initiating the debate, to which I contribute with great humility.

I cannot match the knowledge and expertise manifest in some of the speeches that have preceded mine, and which will no doubt be further manifest in those that come after. I have never worked in or around the National Health Service and I am glad to say that, so far, my family and I have had need to use it relatively sparingly. None the less, I regard it as one of the UK's--and, I venture to say, the Labour Party's--finest 20th century achievements.

In referring to the NHS specifically as a 20th century achievement, I should like to draw attention not to the difficulties and disappointments of the present--on which some noble Lords have understandably wished to dwell--but to the challenges of the future; and, in particular, how we can learn to understand and make better use of the health services that will be available to us as the century goes forward.

As medical science and technology have advanced, which--as other noble Lords have pointed out--they have done at a startling rate over the past 30 years, the

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expectation has grown that medicine can and should put right all the ills to which flesh is heir. As others have said, it is that level of expectation as much as any other factor which is putting the National Health Service under such intense strain. If such expectation grows unmediated by informed public debate, it will never be satisfied, no matter how much money is flung into its open mouth.

It is reasonable to expect that our taxes will be used wisely to provide a comprehensive and inclusive health service. There has never been any question about the Government's support for that principle, which perhaps could not always have been said of the previous administration. The Government have done a great deal in their short life to improve the quality and reach of the NHS, adding both significant new money and important new initiatives, such as the introduction of NHS Direct and NICE. But in respect of health services, we are extremely disinclined to accept that we cannot have everything, that choices have to be made and that systems have to change. It seems to me unlikely that we shall ever arrive in Utopia, where enough is not only available but seen and understood to be so by everyone. We shall always face great questions about the allocation of resources. Making the best use of resources, both human and financial, will require in future a commitment from each and all of us to understand what we can and, equally importantly, what we cannot expect a health service to deliver.

In recent years we have learned to identify ourselves primarily as "customers" or "consumers". All organisations supplying products and services have had to adjust to the idea that the customer rules. Of course that is not in itself a bad thing; indeed, in many respects, it is a good thing. We should expect that those who provide us with milk, gas, insurance, or, indeed, theatre, will do so in a way that suits us. If they do not, we can take our custom elsewhere the next time we want something similar. But we have come to apply the customer test to everything and I wonder whether seeing ourselves as "consumers" of healthcare is, as it were, healthy.

Of course, the old-fashioned paternalistic model of the doctor/patient relationship will no longer do. We have seen in recent days, unfortunately, a dreadful example of what may happen when it is too heavily relied upon. But that relationship between ourselves as patients and our doctors as service providers, whether they be general practitioners or the hospital services to which we turn, is not like the one we have with the gas company with which we contract for a safe supply of gas at an agreed price. It is, or should be, much more in the nature of a partnership--and indeed, that is how it is now often described. The point about a partnership is, of course, that both parties have expertise to offer and responsibilities to discharge.

I fear that if we cannot learn to see ourselves as active participants in decisions about our own health, rather than merely as consumers of a service, we shall never become sophisticated enough as a society to deal with the complex, and often contradictory, challenges

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with which advances in medical science, demographic change and constrained resources will increasingly present us.

The way that the NHS and health issues in general are discussed in the press and other media has not always helped us to think constructively about the difficult questions we face. The relentless concentration on crisis and on individual cases, whether, as it were, "tragic" or "miraculous", distorts our perceptions, creating heroes, fuelling witchhunts and appealing to sentiment rather than reason.

One most revealing recent example concerns the case of Jaymee Bowen, otherwise known as "Child B", who, noble Lords may remember, died aged 11 of leukaemia in May 1996 following a highly-publicised confrontation between her father and the Cambridge Health Authority over whether she should receive further treatment. A team of researchers at the University of York analysed the media coverage generated by the case. How confused and reductive public debate on that issue may become is illustrated by what they show. That is not to say that the matter was not treated seriously by the media, which it certainly was; nor that all commentary was simplistic, which it certainly was not. The question is whether we, the public, were equipped to make sense of the information available.

I should like to highlight a few of the conclusions reached by the research team, which seem to have general application:

    "Media coverage of the Child B case might be seen as an indicator of a widespread expectation that modern medicine can cure every ill and provide a solution to every problem.

    It is not clear to what extent media coverage of this case would have helped people understand the limited nature of available research evidence about the effectiveness of health care interventions or about the inherent uncertainty attached to medical decision making.

    Our study suggests that while the media may raise awareness of the issues which need debating, and may influence people's perceptions of these issues, they do not provide a solid base of information which would allow people to participate in debates in a particularly informed way, and their coverage itself does not constitute a full public debate".

It is not my intention to lay all the blame for the inadequacy of public understanding entirely at the door of the media. That would be easy, but hypocritical. If we are to do better in future, it will not be through pointing the finger in that way, or indeed, in any other way. It has been helpful that a number of noble Lords have referred to the NHS as an issue which needs to be dealt with in a non-partisan, non-party-political way. However, if we are to raise the standard of debate, we must do so by devoting more time and energy within our education system to addressing some of the painful choices which will face us both as individuals and as a community. The reality is that living in a grown-up democracy means living with complexity and contradiction, and, as T S Eliot famously remarked,

    "Human kind cannot take very much reality".

I hope that your Lordships will forgive me if, at this late moment, I briefly introduce a subject dear to my heart: the use of the arts in education. One of the best

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ways of helping young people to get to grips with difficult issues and to recognise the personal responsibility involved in good citizenship is by using the arts as a medium for discussion. On a previous occasion I have drawn the House's attention to several examples of how that can work, particularly in the area of health, and I know that the Government are interested in, and supportive of, some of the initiatives already under way.

The Government have not shirked the challenges that sustaining a comprehensive National Health Service presents. However, we cannot leave it to Government alone to face those challenges. The future health of the National Health Service lies in our collective ability to value it, support it and understand it in an informed, mature way. I do not expect that that can be achieved overnight, but I hope that we can by slow degrees reduce the danger that public perception of difficult issues will for ever be dominated by political opportunism and journalistic hype.

4.48 p.m.

Baroness Emerton: My Lords, I thank the noble Baroness, Lady Cumberlege, for introducing this important debate on the state of the NHS. There is no doubt that in this country we have much to be proud of within the NHS. The recent millennium preparations demonstrated how good interagency planning can deliver a service to meet the needs of patients. I hope that the excellent work undertaken will not be put aside, but developed still further. However, the millennium period was followed, as we have already heard, by extreme pressure on the services due to the outbreak of influenza and its complications. Those pressures, which were referred to as "winter pressures", cannot be ignored.

Research evidence shows that an efficient hospital runs at 85 to 86 per cent occupancy. My experience is that the hospitals in the trust which I currently chair are running at 96 to 98 per cent--sometimes 99 per cent--occupancy, and not just confined to winter pressures. I understand that that experience is shared by many other trusts, as was stated by the noble Lord, Lord Clement-Jones, earlier in the debate. That cannot be an efficient way of running the health service.

There is no doubt that the health inflation rate is not met by the national inflation rate. It is perhaps best described as an irresistible force of healthcare demand and the requirement for quality service meeting the immovable object of inadequate resources--for example, in bed capacity, especially in intensive care units; shortage of manpower and money; and with ever increasing numbers of elderly people in the population requiring more healthcare. Research shows that elderly people--those over the age of 85--need four times as much healthcare as those aged 65 to 75. The Government have allocated 6.7 per cent more cash. However, once the unfunded pay awards and the European working time directive, which will take up 2.5 per cent, the NHS superannuation pension scheme, 1 per cent, prescribing cost increases, 2 per cent, and inflation increases, 2.5 per cent, have been deducted

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then, when allowing for a planned 3 per cent efficiency gain, there is little resource available for health authorities to allocate to primary care groups and NHS trusts, where there are competing priorities--for example, in replacing out of date equipment essential for modern diagnostic and treatment procedures, investment to meet the target of single sex wards, to say nothing of the manpower requirements in all healthcare professions and the exciting new models in primary healthcare teams and community developments.

The NHS is one of the largest and most complex organisations in the United Kingdom. The Government's policy to modernise the NHS is welcomed by, I would say, almost all health professionals. But change cannot happen overnight. There is a need for time, for change management expertise and for resources to effect the changes. Currently, employees--be they managers, doctors, nurses, physiotherapists, pharmacists, to name but a few--are all engaged in the day-to-day delivery of care, desperately trying to maintain high quality care and to meet government imperatives on waiting times. The reconfiguration of services requires clinicians to spend time discussing, planning and programming changes to their services. Yet they are expected to continue with their clinical programmes. To attain the modernisation programme, a realisable target timetable must be set and there must be the manpower resource to plan and implement it, which requires additional resources. Can the Minister indicate the Government's intention with regard to resources being made available for planning and implementing the modernisation programme?

Within the past 10 years, the nursing profession has been transformed into a more confident forward-looking profession with enormous potential to prevent disease, provide high quality care for the sick and promote healthier lifestyles. One example of the way in which a more cost-effective and more efficient service could be established is to expand the various models of high quality, cost-effective healthcare through nurse-led services, NHS Direct, assessment and pain control clinics, screening clinics, specialist roles in endoscopy, colonoscopy, nurse practitioners, Hospital at Home services and a range of community services within the primary healthcare team and expansion of the nurse prescribing programme. It would be helpful if the Minister could say whether the development of these nurse-led models which result in high quality cost-effective healthcare will be supported by the Government? For example, one of the UK studies demonstrated that nurse practitioners were more cost-effective in all areas of care, with 84 per cent of patients reporting a high degree of satisfaction. Hourly rates for a nurse practitioner are £11 to £15 compared with £25 for a general practitioner.

The promotion of the integration of clinical services and information for health within the framework of clinical governance is an integral part of delivering a high quality health service. We need reassurance that there will be a continued drive by the Government to implement that.

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The NHS is very important to the people of the UK. The healthcare professionals are dedicated to providing a high quality service. That dedication needs to be fostered before good will runs out. There is a limit to how much more pressure the current workforce can take. As was pointed out by the noble Baroness, Lady Sharp, earlier in the debate, nurses are resigning. I urge the Minister to bear this in mind as the Government unfold the much needed modernisation programme, which needs to be more radical. As the noble Lord, Lord Forsyth, suggested, this debate presents a window of opportunity.

4.56 p.m.

Lord Rea: My Lords, noble Lords may have some apprehension at the prospect of being addressed by a GP such as myself, with a grey beard and a grey moustache, but I can reassure the House that I have no malevolent intentions. As the Shipman case is still headline news, perhaps I may welcome the Secretary of State's prompt and wise choice of the noble Lord, Lord Laming, to head the inquiry into the case. I am sure that most doctors will agree that the General Medical Council should tighten its follow-up procedures for those doctors who have been disciplined, as was Dr Shipman in 1977. Single-handed practitioners need particular support and appraisal.

The paradox of Dr Shipman is that he seems to have been a good Dr Jekyll when he was not being a Mr Hyde--apparently, a caring, concerned man in whom many put their trust; in fact, the very kind of doctor who was typical of a past era that is mourned by many. The current stereotype of a general practitioner or a hospital doctor is one who is in a hurry, under stress and has a reductionist or technical approach. As my noble friend Lord Walton said, that may play a part in the current popularity of complementary and alternative medicine.

I intend to raise three points and spend perhaps one and a half or two minutes on each. My first point concerns NHS Direct. It is a popular service and is now to be expanded. What evaluation of the service has or is being done? When can we expect to see a report? I was always sorry that the scheme was not integrated more closely with primary care groups--in particular, GP off-duty rotas or co-operative schemes--or that it did not involve practice nurses. Perhaps more practice nurses could have been added to practices for that purpose. They would be able to liaise more directly with GPs when that was necessary, as it so often is. It is not too late to do that. Continuity of care would be much better if there were closer local links between the nurses who give advice through NHS Direct and local primary care groups or practices. Perhaps my noble friend will be able to give a progress report.

I turn to the present bed crisis--always with us at this time of the year but particularly acute this time round. I am concerned that the PFI-built hospitals now coming on stream will exacerbate the problem rather than solve it. In nearly every case fewer beds are

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provided in the newly built PFI hospitals than in those they replace. For instance, according to a BMA report in May last year, at Dartford hospital,

    "The loss of 75 beds compared with the existing provision in the three hospitals will require a further shift to more out-patient and day case treatment".

    "Yet hospital consultants already work on average more than 51 hours a week, and 1 in 6 junior doctors is working in excess of 56 hours each week. The BMA regards a rise in work intensity of this nature as unsustainable"--

let alone the burden on nurses, which is equally great.

Regarding the new PFI-built Royal Infirmary in Edinburgh, in which bed numbers will fall by no less than 21 per cent,

    "The British Medical Association has warned for several years that the hospital would prove to be too small given the need to provide a profit margin to the PFI consortium".

The PFI has been very useful in giving a boost to the hospital building programme, but it seems that short-term gain is being obtained at long-term cost--not only in numbers of beds and pressure on staff, but also by passing higher than necessary interest rates on to future taxpayers, whose governments will have to find the money from their current National Health Service expenditure, causing costs to escalate further. The British Medical Journal uses the phrase, "perfidious financial idiocy", in describing the PFI. I hope that we shall have time later in this parliamentary Session to discuss the whole issue of the PFI and how it is developing.

Finally, I should like to congratulate the Prime Minister on his avowed goal of reaching the average European Union percentage of GDP spent on health. We must beware, however, that it is a moving target. As we still spend a lower proportion of our health budget on administration than other EU countries, we should do quite well if we can reach that average, providing we continue to fund the NHS, as we do now, from general taxation, as well as possibly from national insurance contributions with the upper ceiling removed. That might have the same effect as the proposal of the noble Baroness, Lady Cumberlege. I am also attracted to the hypothecated tax suggested by my noble friend Lord Walton.

My main fear is that increased funding for the National Health Service will result in a reduction in resources for the other departments whose responsibilities have an equal or greater effect on the health of the population than the National Health Service. The major public health problem in the United Kingdom--and for that matter most of the rest of the world--is the inequality in the health of the poorest and that of the better-off. Poverty, poor education, poor housing and inequity of income lie at the root of this, as has been shown in study after study.

In his introduction to a new book, The widening gap, published by a team from Bristol University, Professor Peter Townsend states:

    "If the Conservative government had not reduced social security benefits, it can be estimated that the poorest 20% of the population would today have about £5bn, or 20%, more in aggregate disposable income, that the ratio between the richest

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    and poorest 20% would be reduced from about 9:1 ... to 5:1, and that poverty by European standards would have been reduced by more than a third".

A greater long-term gain in the health of the nation would be achieved by eliminating poverty and reducing income inequity than any amount of expenditure on the National Health Service. An improved National Health Service is politically and socially necessary. But the Government should not deviate from their main self-appointed task; namely, to work towards a fairer society. That would also be a happier and healthier society.

5.4 p.m.

Lord Chadlington: My Lords, I am, in common with other noble Lords, most grateful to my noble friend Lady Cumberlege for introducing this important debate.

As always, my noble friend has spoken with customary grace and good sense. In a weak reflection of those excellent opening words I, too, urge the Minister to ask whether the time has not come for the health service to be taken out of the day by day political ping-pong and point scoring of modern politics. Is it beyond the resolve of all the political parties to find common ground on certain aspects of, for example, the NHS delivery system? There seems to me to be something fundamentally unacceptable about political point scoring when dealing with the health and lives of the people of Britain; the health and lives of the very people we in these Houses of Parliament are here to serve.

When I was a member of the NHS Policy Board between 1991 and 1995 there was much debate, often encouraged by my noble friend Lady Cumberlege, about the possibilities of establishing an independent board to run the NHS, staffed by executives and non-executives from the private sector, thus distancing these day by day issues from the politics of the day.

However that is done, the need is urgent: put the NHS above party politics, agree common ground across the main parties and establish long-term strategies to invest in and develop the NHS which will not be altered on political whim or simply when there is a change of government.

The opportunity is dramatic. The scale is enormous: a million people working in the NHS; 800,000 people treated every week in hospital out-patients departments; 700,000 going to a dentist; 8.5 million prescriptions; 10,000 babies delivered; £47 billion of public money a year.

Consistent with fulfilling the constraints of the proper stewardship of public funds, as other noble Lords have said, we must find a way of rebuilding public confidence in the NHS. In the White Paper, The New NHS: modern, dependable, prepared in December 1997, the Government propose,

    "to rebuild public confidence in the NHS as a public service, accountable to patients, open to the public and shaped by their views".

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In a similar debate a year ago, I urged the Government to trumpet the everyday triumphs of the NHS. I have just listed the vast weekly output of the NHS. Much is wrong, but the overwhelming majority of its activities are not subjects of complaint or dissatisfaction. To the contrary, many of those who use the NHS praise its quality and praise those employed within it. Those achievements go largely unheralded.

I spoke previously of the importance of building a reservoir of goodwill upon which to draw when things go wrong. The goodwill towards the NHS is too often lost by one single picture in one single tabloid suggesting that the norm is a bed in a corridor or the inability to afford certain drugs or treatments. We should not rest until those inequalities are removed, but they are still the exception and not the rule.

But the good news of the NHS--so essential to the confidence of patients and to the morale of all those who work with such selfless determination within it--has not been promoted. In fact, the situation has deteriorated. In the light of my earlier comments on de-politicising the NHS, I turn, rather reluctantly, to the Government's record. I do so because it underlines once more the public dissatisfaction with that politicisation, and adds weight to my noble friend's basic proposition.

A recent Gallup poll found that more than half the respondents confessed to dissatisfaction at the way in which the Government are running the NHS. A similar poll in the Observer reveals the depth of scepticism: two-thirds of the public simply do not believe that waiting lists are getting shorter. The same poll found that only one in three people expect the NHS to improve over the next three or four years.

But this is not just about perception; it is about reality. The New Labour manifesto declares:

    "We want to save and modernise the NHS".

But let us consider the facts. Waiting lists, and their coverage in the media, are what the public see. They are the bell-wether of public confidence. Labour pledged in its manifesto to cut inpatient waiting lists by 100,000. However, while the headline waiting list figures have come down by 87,000, the number of those waiting for more than three months for out-patient appointments has more than doubled from 250,000 to half a million--solving one problem and creating another. We were promised that 18-month waits for inpatient treatment would be eliminated by 31st March 1998. At the end of November 1999, 69 patients had been waiting for inpatient treatment for longer than 18 months.

Seeing a specialist is not the end of the line. According to the NHS Quarterly Review, the number of last-minute cancelled operations rose from 11,470 in the second quarter of 1998-99 to over 12,000 in the second quarter of 1999-00. That was the highest ever second quarter figure since records began.

I also draw attention to waiting times to see a specialist in cases of suspected breast cancer. The Government's White Paper stated that by April 1999 everyone with suspected breast cancer would be able to

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see a specialist within two weeks of the GP deciding that the patient needed to be seen urgently. Figures available from the NHS Executive for the quarter ending September 1999 suggest that even six months after the deadline has passed this has not happened. Over 10 per cent of suspected breast cancer patients were not seen within the required two weeks. That is simply not acceptable.

I conclude with a five-point agenda. First, can we take some, much or all of the NHS out of the daily political exchange? Secondly, can we initiate a programme to publicise the successes of the NHS to raise the confidence of the public and the confidence and internal morale of the organisation? Thirdly, if this or any other government sets targets can we ensure that they are met? It is better to set low targets and build confidence than macho targets and fail. Fourthly, can we establish a better way to measure outputs which the media also regard as meaningful and can be agreed across the party divide, rather than the artificial measure of waiting lists?

The fifth point is the most worrying of all. For the first time there are strong indications that the public approval rating of the NHS is dropping among the young. It may be a blip but I believe that it is a trend. A political system which does not deliver a health service for the young of which they can be proud fails the country as a whole. As my noble friend Lord Forsyth of Drumlean clearly stated, it is a unique agenda for a young modernising Prime Minister to change for the better the future of every man, woman and child in this country. He should grasp it with courage and enthusiasm.

5.12 p.m.

Lord Davies of Oldham: My Lords, I express gratitude to the noble Baroness, Lady Cumberlege, for introducing this debate. She will recognise from the way in which she introduced this subject, and the subsequent speech of her noble friend Earl Howe on the Opposition Front Bench, that this debate poses as many problems for her side as for the Government. We all recognise that one of the great features of the National Health Service is the very long-term nature of the policies related to it. All of us who are involved in the public debate when the electorate makes its choice every four or five years in the general election recognise that the timespan of some issues, which are exceedingly difficult to deal with, goes way beyond that period. That is certainly true in considering the resources of the National Health Service.

It takes eight years to train a doctor and many more years before a newly-qualified doctor achieves consultancy status and can play a significant part in the health service. Therefore, it is inevitable that in this debate we use catch phrases to identify the particular priorities of the moment. We recognise the limited significance of a policy to reduce NHS waiting lists against a background where it is an earnest of intent by which the Government can be measured given the short timescale within which they are forced to operate. This debate gives us the opportunity to look

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at the longer term, and I hope that in the course of my short contribution I shall be able to concentrate on some of the issues in that context.

It is noticeable that in the debate thus far no one has commented on one contribution that the Government have already made to morale in the health service. I am all too well aware of the strains on health service staff at every level. Can anyone in this House recall when a government last decided to implement in full the recommendations of the review bodies concerned with health service pay and conditions? Surely, that is an earnest of very real intent.

But we accept that we have finite resources to meet an infinite demand. Demand increases with demographic changes. The ageing population alone increases the demands upon the health service. Technology, whether it be the development of new and expensive drugs or surgical techniques which become more generally available, produces its own cost escalator; and the expectations of people rise with every new discovery. Therefore, the inflation index that is appropriate for the health service is higher than that applied to the broader economy simply because NHS costs have an escalator within them. For that reason we need to concentrate on lower cost solutions.

There is no doubt that we can do a great deal more by concentrating on preventive rather than curative medicine. Emphasis on primary care and education, in whatever form, to ensure that people adopt strategies that make them less dependent on the expensive resources of the health service will assist. I also have in mind the more intelligent use of the support professions; for example pharmacy. In France, access to doctors is reduced because a significant amount of assistance is offered by pharmacists--far greater than ours are empowered to provide--at lower cost. We should look at international comparisons in relation to that practice, which I do not believe gives rise to concerns about political ideology.

I drafted one part of my speech in advance of the horrors of the past few days. I wanted to emphasise how important it was to change the relationship between those who consume health services--the general population--and the health professions. I find it difficult to express general points at this stage when the Shipman case illustrates with all its horror the particular problems that arise when a doctor abuses trust in such an extreme way. We all know that that was a bizarre, horrific and unique case, but, surely, the issue with which we should be concerned is the need for an effective way to measure performance and competence, let alone probity, to reassure people.

We should recognise the steps that the medical profession has taken to develop techniques to improve the measurement of competence. The assessment of GPs on a regular basis is being introduced. That system looks at whether a GP's practice, whatever his level of experience, is perhaps somewhat dated compared with the rapidly changing world in which we now live. His competence will now be adequately measured, and I believe that that will go a considerable way to meet the kinds of concerns raised by the

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previous speaker, who spoke about the re-establishment of confidence in health service delivery. I agree that that is of supreme importance to all of us.

Despite the general propositions referred to in this debate, how can there ever be division among well-meaning people as to the desirability of providing the best possible healthcare that the nation can afford? Perhaps I may add to the aspiration adumbrated by these and other Benches. There are considerable merits in a health service which provides care at the point of need irrespective of ability to pay.

However, as regards increasing resources, while we on this side of the House envisage great difficulty in increasing the tax burden upon our people, private insurance as a solution is a non-starter. At present, private insurance aids the queue jumper and the advantaged against the ordinary member of the public. Private insurance concentrates upon those who are good risks in healthcare rather than the poorest. The private health service concentrates upon operations with high success rates which are relatively cheap. And--one might ask the Americans about this--a private health service is enormously costly to administer.

5.20 p.m.

Lord Lucas: My Lords, we no longer have time for Ministers who say that there is no crisis in the National Health Service. Those of us involved in the service--I have seen a great deal of it in the past two years from a patient's point of view--can only conclude that the NHS is in deep and almost intractable crisis. It is a time for honesty, openness, and facing up to facts. We need to think long term. We need to cast aside dogma and--I look hard at my Front Bench--political point scoring.

Looking back, we had every reason to be proud of the health service. We are proud of the people who created it. We are grateful to the people who serve in it now. But it is hard to be proud of the NHS now. Why do we put up with waiting lists? Other countries do not have them. Waiting lists do not serve any clinical function; they cause a great deal of distress to those who endure them. Why should we put up with the fact that we are not seen by a doctor until after midnight when we have arrived at casualty at five o'clock with a broken leg? Why should a person have to wait in casualty for six hours to see a doctor when, for example, his child has swallowed a coin and has to be kept calm, without food or water? Why should we put up with hospitals which are decaying, under-staffed and under-equipped?

Why should we put up with GPs who are so overstretched that they have no time for patients or to keep themselves up-to-date with modern medicine? If I wanted to book an appointment it could be the middle of next week before the GP would see me.

We are an increasingly wealthy country. There is no reason why we should put up with a National Health Service in this condition. If we paid personally for the service, it would have gone long ago. We would not put

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up with being treated in that way by Tesco or any other supplier. It is only because it is paid for by government. It is because over the years my government and other parties have imposed cash limitations far below the amount that we, the people, would wish to see spent on healthcare that the service is in its present awful state.

We know that we have to pay more for the National Health Service. We do not need to look as far as Europe for a comparison. All we need to do in England is to bring our spending up to the standards that we provide for the Scots. The figure is 30 per cent higher per capita in Scotland than in England. I find it hard to understand how we can justify not bringing ourselves up to that standard. It proved impossible for my party to do so in the face of fire from the Labour Party on the financing of the National Health Service. It should be easier for the Labour Party to achieve that.

The solution is surely for the Government to involve all the people in the difficult decisions government must take. They must carry the public with them in decisions on how the NHS should be financed. If we were part of that decision-making process, we would not criticise the Government when they increase taxes or impose a specific levy to fund the NHS.

The Government should carry the public with them as regards the limitations of the NHS. Clearly there must be limitations because technology is racing ahead. Those limitations should be agreed by consensus. There must be a process whereby public opinion is taken into account by the NHS. Such a process was instituted as part of the GP fundholding scheme. While it may have had faults, it was a start in the right direction. Having destroyed that start, the Government have a duty to begin again.

We have to consider how we pay for the National Health Service. I share many of the doubts expressed by noble Lords opposite about the efficacy of insurance funding. It tends to introduce extra costs into the system. For instance, with car repairs insurance companies may pay twice the amount paid by the individual who pays for the repair himself. We should make comparisons with France, Germany and other countries which share similar beliefs about the social contract between government and people. There are other solutions to be considered.

The noble Lord, Lord Desai, raised some pertinent questions about a service which is free at the point of delivery "but you can't have it"--a form of rationing. We need to face up to these problems. We in this party need to ensure that we do not cast caltrops in the path of the Government merely to make their existence painful, thereby disadvantaging our citizens who need the Government to take long-term and difficult decisions.

We need a government who will give more information on the health service. We are becoming more capable, more involved citizens. In order to participate, we need information. We should institute a system of inspection. Clearly the results achieved by a doctor, say, in cancer surgery are significant. Some doctors achieve far better results than others

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performing similar operations. A patient cannot judge that. One does not know the circumstances or the patients. We need a qualified inspectorate. Those inspection reports need to be made public, at least to GPs. GPs need to be able to refer their patients to the specialist of their choice. We may be able to compare one hospital with another but a GP has no choice for referral. He has to take what the local hospital offers. That is not good enough. We need choice for GPs and for patients.

We also need choice as regards conditions in hospitals. It is possible to find one ward in a hospital where the quality of nursing care makes one think one is being looked after by angels; and 30 yards away in another ward the staff have horns and pitchforks and make the patient's life a misery. There is no control or check. There is no auditing of the quality of care for patients. We need proper information about what is happening within the NHS.

People who work within the NHS need to be able to keep up to date with information. The systems are primitive. There is so much information that it is hard to absorb. The Internet will be a great boon, in particular when we have high data rates on it. The Government should pay a great deal of attention to that aspect.

We need a fundamental consideration of the roles of those working within the NHS. Why do we insist that an individual who wishes to become a GP has three of the best A-levels? We want them to like people and to have a certain amount of common sense. We are training the wrong people for the wrong job.

We need to ask many questions. We should not make it difficult for the Government to answer them. We should judge whether the Government are prepared to address those issues honestly and openly, and involve us in the discussions.

5.30 p.m.

Lord Harris of Haringey: My Lords, I declare an interest, first, as a non-executive director of the London Ambulance Service and, secondly, as adviser to a number of companies with an involvement in health matters. Perhaps I may thank the noble Baroness, Lady Cumberlege, for introducing the debate. She has a long history within the health service and our paths have crossed on a number of occasions in various guises.

The noble Baroness made a most interesting speech. Most notably she spoke of the inexperience of today's top management team in the NHS which is subject to the capriciousness of political change. That made me think about my time from 1987 to 1998 as director of the Association of Community Health Councils. I calculated that I got through seven Secretaries of State for Health. Six of them were Conservative and I claim no part in that. However, I remember them all vividly because at one stage or another they all publicly denounced me--as did my right honourable friend Frank Dobson when he was Secretary of State. Clearly, I was doing something right--or wrong--during that period.

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However, to say that there is a problem with the NHS because of that political system of management raises big and wide issues about our system of government. I suspect that they are beyond the terms of the debate and perhaps beyond the terms of the noble Baroness's proposals.

Having heard the speech of the noble Lord, Lord Chadlington, I am confident that the purpose of the debate is not to capitalise on the difficult few weeks experienced by the NHS and indulge in political point scoring. After all, we are in what the noble Lord, Lord Forsyth, called the annual January crisis. But the events of the past few weeks have triggered a significant debate on NHS funding which I believe has been based on false premises. The speech of the noble Lord, Lord Lucas, pointed up the problems with the Conservative's solution of insurance: that it is likely to cost a lot more. We shall require a greater contribution from GDP if we go down that route.

It must be recognised, first, that the NHS cannot do everything for everybody and it is proper to debate the limits to what is or is not appropriate for the health service. But it is also proper and right to debate the effectiveness not only of new treatments and drugs but of existing and long-established treatments. It used to be said that only 10 per cent of treatments were proven to be beneficial, that another 10 per cent were probably harmful and that the rest were unproven one way or the other. I am sure that that is apocryphal and I am not sure that anyone is in a position to test it. However, it is right and proper that we should institute arrangements which demonstrate whether the bulk of expenditure in the health service on particular treatments and procedures is well spent, appropriate and in the interests of the public.

In that context, the promise made by the Prime Minister on David Frost's sofa is enormously important. It is probably the most important statement made about the future of the health service for many years. It is a major long-term commitment of government investment in the NHS. However, I am worried that the tone of the debate has often suggested that the NHS is a drain on the nation's GDP. In fact, it makes a major contribution because the fact that the NHS succeeds in making us healthier means that we are all able to make a greater contribution to the nation's income.

The Government have already done a great deal for the health service. There has been a substantial cash improvement--more in real terms per annum than during previous governments. A major building programme is under way. The Government have recognised the importance of quality, introduced clinical governance and the Commission for Health Improvement. They have brought general practice into the managed framework of the NHS, which, as the NHS Confederation points out, is crucial in enabling improvements to quality. They have introduced the national service frameworks and they are introducing the drop-in centres and NHS Direct.

The noble Baroness, Lady Cumberlege, talked about her two reports and the theme of giving people power. There is a trend which one can discern over a

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number of years; first, from a time when we all expected doctor-led decision-taking: the doctor knew best. More recently, there has been an expectation that doctors will listen; that the GPs will take decisions having elicited the patients' views.

We are now moving into an era in which we should expect shared decision-taking; where the GP and the patient share information and then together reach a decision on the appropriate course of action. But I suspect that we shall rapidly reach a place where there is patient-led decision- taking; where the GP provides the information and advice and the patient decides on the basis of it.

Yesterday, I spoke to a GP who confirms that most days someone visits his surgery who has already looked up his condition on the Internet and is equipped with a great deal of information about it. I am told that statistics show that half of Internet users access health sites. Indeed, health matters are almost as popular as pornography on the Internet!

However, using the Internet, it is difficult to find specific information in respect of health. There must be questions about whether or not the information provided is accurate. Often it is sponsored by those with an interest; for example, a drug company. So what the public need is evidence-based information to help them make decisions. It could come through NHS Direct, whether by telephone or the new Internet service, but also through leaflets and videos. Most patients welcome more information. It leads to less conflict with doctors and it changes behaviour. There is evidence, for example, that surgery intervention in prostate treatment declines substantially if people are provided with sufficient information. Patient information leads to better healthcare, better compliance and better outcomes.

I am concerned that NHS Direct is being offered as a solution to the problems which may or may not exist in acute care. The monitoring information that I have seen about one pilot suggested that, yes, it was true that the number of people who were otherwise planning to call an ambulance or take themselves to A&E were persuaded that that was unnecessary. However, a larger number than those who were dissuaded, who had been planning perhaps to wait and see their GPs, were told to go to A&E or to call the ambulance service. Therefore, it is a fallacy to believe that these services will reduce demand on acute services.

My view is that NHS Direct and the drop-in centres are new, valuable services but they might not reduce pressure on established areas of service. They provide an opportunity to create a modern people's NHS. As NHS Direct protocols develop, and as the computer systems develop, there is an opportunity to provide a universal system of triage; one which can be applicable in a GP's surgery, a hospital waiting room and used in a variety of contexts. Once you give everyone a smart card and unique IDs containing their medical records, that information can be accessed as part of the service,

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forming something which is truly interactive. Vitally important opportunities exist and they must not be lost because people expect too much from NHS Direct.

The NHS is popular; it is a people's service, and it needs to prepare for the future in which patients expect much more in the way of information, choice and respect from NHS professionals.

5.38 p.m.

Lord Addington: My Lords, I thank the noble Baroness for introducing the debate. I hope that noble Lords will bear with me if I go off at a slight tangent, although I do not believe that I shall be totally alone.

Most of the debate has been about someone dealing with a pool of water in his house. I want to talk about prevention; in other words, I shall be the person who says, "You should have had that pipe fixed", and not offer to get a bucket to get rid of the water.

Much of what is done in the health service involves people who suffer from a more sedentary lifestyle. We are always hearing about bad sport facilities at schools, fat teenagers and the problems of obesity. A great deal of that is due to the fact that we lead a sedentary lifestyle: we do not walk to work and most jobs do not involve physical activity. That has led to huge cultural shifts and certain medical gains. People no longer have compressed spines or arthritis in their fingers. However, it is undeniable that lack of physical activity leads to health problems early on in life.

However, the discipline of sports medicine may be able to help with those problems through the better training of doctors to give advice. Sports medicine does not exclusively address sport and most certainly does not concentrate only on sport at the elite level. Athletes working at the elite level are operating at 100 per cent of their physical capacity in one particular narrow range of activity. Usually they are trying for 101 per cent. I would not expect the NHS to deal with such activities, for the simple reason that if an athlete had to join a waiting list to get help with a fitness regime for an international event, the athlete would miss the event and clog up the system.

In 1977 a definition of sports medicine was universally adopted, brought forward from the foundation of the Institute for Cardiology and Sports Medicine in Cologne in 1958:

    "Sports medicine includes those theoretical and practical branches of medicine which investigate the influence of exercise, training, and sport on healthy and ill people, as well as the effects of lack of exercise, to produce useful results for prevention, therapy, rehabilitation and the athlete".

That suggests that we can learn from sports medicine.

Unfortunately there is no career structure in this field within the medical system of the National Health Service. There is no provision for people to be trained. The House has just heard a speech which rightly pointed out that information is extremely helpful. Doctors need to be able to give out accurate information, but often doctors are not well qualified to help their patients with lifestyle information.

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I approach this subject from the point of view of a sportsman, complete with the familiar horror stories that are shared by many sportsmen of my age. When you visited the GP with a leg injury, he would stare blankly as you described what had happened and then say, "Rest for six weeks". If pressed, he would then say, "Rest for 12 weeks". The muscle on the damaged leg would lose both quantity and quality, the ligaments would shorten and the entire limb would be weaker. When you returned to play there was an excellent chance of incurring the same injury again.

All forms of exercise can be of benefit and all forms of exercise enable people to become healthier individuals. The athlete is only an extreme example of that. Older people would benefit from exercise by becoming healthier. In old age one of the main forms of disability is when a person can no longer achieve a sitting position unaided. That is in fact a definition of disability. It is caused by loss of muscle tone and quality. Osteoporosis is helped by changing from a sedentary lifestyle. The simple act of walking will toughen bones. Such activity--I shall not go into detail because far too many doctors are contributing to the debate today--must be encouraged.

However, unless doctors are trained to give correct advice, which at the moment they are not, the problems will continue. While I appreciate that the general medical education of doctors will cover all these areas, doctors--like everyone else--need plenty of specific information. That is because they are important conduits of information to help everyone achieve a healthier lifestyle.

Furthermore, provision must be made for everyone to be able to change to a healthier way of life. Diet is of course vitally important, along with adequate advice on alcohol consumption and smoking. Nevertheless, concentration on physical activity is one of the most effective methods of achieving better health. However, if you live in a town with no gymnasium or swimming pool--in recent years my own City of Norwich has lost two of its public gymnasiums and a swimming pool--it can be very difficult indeed to take proper exercise. Trained staff must also be on hand to give accurate advice and help to implement the doctor's plans. If this form of medicine were taken more seriously, by ensuring that consultant posts were established, that would send a clear message and provide a strong incentive for the area to expand.

I do not know whether the provision of gymnasiums should be part of the remit of the health service, but I do believe that they could be justified as part of a wider health programme. Such provision would eventually cut down on the number of people making demands on the health service. A healthy and strong person will throw off the effects of flu far more speedily than someone who is not. We should adopt a holistic approach and, to an extent, implement joined-up government in this area. If we did this, we might also produce a few more first-class athletes, as well as get rid of some podgy teenagers.

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I believe that well-structured fitness regimes forming part of the whole healthcare programme would have many benefits. For instance, it would be possible to speak at length on the wider benefits of sports activities such as greater social inclusion. However, until the entire approach to fitness and exercise changes, we shall not be able to deal with increasing levels of poor health that are the result of the basic fact that people have allowed themselves to deteriorate and are looking to the National Health Service to provide a Band-Aid for a bad lifestyle.

5.45 p.m.

Baroness Hogg: My Lords, I am delighted to rise from my sedentary position and congratulate my noble friend Lady Cumberlege on her timeliness in initiating this debate. Its quality attests to the high standard she set in her introduction. Since the wider health debate erupted recently, I felt at first a twinge of sympathy, first, for the noble Lord, Lord Winston, on whose Select Committee I have had the honour to serve, and, secondly--dare I say this?--for the Prime Minister. That is because I have been there. An interview hits the headlines, the Prime Minister must respond, somebody grabs a line to take, the Treasury erupts and the department has not got a clue what the Prime Minister is talking about. It is all very familiar.

However, my sympathy has been somewhat eroded because of a tendency on the part of the Government to cover up confusion about the figures by saying that it is someone else's fault, notably the Government's predecessors. I am glad to say, however, that this afternoon's debate has been almost entirely free of such comments. However, I have taken the trouble to make some basic calculations derived from published data. If one examines what has happened to net spending on the health service over the past decade, it is clear that over the seven years of the premiership of the previous Prime Minister, real spending on the health service increased by 3.5 per cent a year. In the first two years of this Government, net spending has increased by 3 per cent a year. I mention that not so much to make a statistical point, but to emphasise the importance of looking at outcomes. As anyone who has ever battled over numbers with the Treasury knows, the truth is that plans rarely turn out exactly as may have been indicated.

That is not only because of annual juggling to cope with temporary crises, but because those plans also depend on forecasts for inflation. Even with the low levels of inflation this Government were lucky enough to inherit, small movements in inflation can push the real increase in health spending up or down by as much as one half. That is why it is important to focus on outcomes because that enables one to look at what has happened to costs in the health service. Many speakers have emphasised the fact that costs in the health service do not always move in line with costs in the economy as a whole. Over the past two years, it is clear that the Government have been squeezing down costs, basically by holding down health service pay.

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I do not believe for one moment that there is some kind of entitlement to a rate of pay. However, I do say that those who run the health service have a responsibility to deliver rates of pay that will attract and retain staff. It is simply no good to say that it is all a matter of long-term planning if good staff cannot be attracted and retained. A great deal has been made of the recent increases in pay, but as the noble Baroness, Lady Emerton, graphically pointed out, a large chunk of this year's increase for health service costs will be absorbed by extra changes, notably, I am sorry to say, in regulation. Therefore, there will continue to be a squeeze, and it cannot last.

For approximately 100 years hospitals in this country relied on dedicated but not highly paid work by women because there were not many other respectable jobs that women could do. Those days are long gone. Approximately 88 per cent of the health service still consists of women, for which the health service has to compete in a completely different labour market. It will not recruit or retain unless it pays the rate to do so.

The Prime Minister has given a commitment to increase spending on the health service. I am sure that we shall hear from the Minister rather more about what that commitment means. He started by saying that he would raise spending in this country to the average for the European Union as a whole. I do not need to take a great deal of your Lordships' time to say that it has been pointed out by many people that 5 per cent increases in health service spending simply will not fill that gap. Not on the most favourable interpretation over a five-year period can they even fill half of the gap. However, we are then told by Downing Street that the Prime Minister was referring to the gap between public sector spending in the United Kingdom and the rest of Europe.

On that point, I am a little puzzled. Is the Prime Minister saying that the gap in health spending between this country and Europe will be filled by private healthcare spending? It would require us to treble private healthcare spending over a five-year period in order to do so. If that is his policy, I should be most interested to hear it. I do not believe that that is what voters at the last election heard.

Leaving aside that issue, there remains the question of the use of the private sector. Given the direction of some of the policy which comes from Downing Street, I find it puzzling that at the moment the Government should be so reluctant to use the resources of the private sector to fill gaps in the National Health Service. Quite clearly, the system is running at the edge of its capacity. There is capacity in the private sector. As the Financial Times rightly said in a recent leader, it displays a disturbing degree of ideology that Ministers are not prepared to make use of that capacity to provide operations for people who need them, who have their operations cancelled and who have a long wait for their operations.

That is redolent of another attitude which I find very strange. That is the emphasis on the size of the waiting list rather than the length of time one waits for an

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operation. It is of very little interest to someone who has a long wait to know that other people are waiting too. What is important is the length of the wait and how many times an operation is cancelled.

I may have spoken rather strongly. If I have, I apologise to your Lordships. However, I feel that in some ways I have earned the right to do so. The government for which I had the honour to work showed their commitment to the National Health Service in terms of reforms, underpinned with financial resources. Of course, they did not solve all the problems. I have the deepest sympathy for the Minister in managing the health service, acquiring the resources from the Treasury in order to do so, and exploring new means of delivery and financing. However, I am sure that in his reply to the debate we shall not have any nonsense from his Benches about a monopoly of commitment and concern for the health service.

5.53 p.m.

Baroness Ashton of Upholland: My Lords, as chairman of a health authority, I am well aware of the difficulties and problems and also the successes that have faced the health service over the past few weeks. I, too, should like to pay tribute to the noble Baroness, Lady Cumberlege, for initiating the debate, and for the work that she has done for the health service in her years as a Minister, before that, and beyond. I was interested in her comments about the inexperience of Ministers, with the exception of my noble friend Lord Hunt of Kings Heath. With regard to our public services, I wonder whether she agrees with me that the role of government can perhaps best be summed up as that of "steering, not rowing".

I hope, too, that the noble Baroness will forgive me if I disagree with her on the issue of competition. When I became chairman of a health authority, I found two hospitals less than 20 miles apart which were attempting to provide exactly the same services for their populations. Having taught them to collaborate under the direction of the Government, they have now released a new energy to support services for their people. I believe that that has been to the benefit of our population.

Many noble Lords have spoken about the financial questions and issues. I do not propose to try to emulate the speeches that have gone before or those that will come after mine. I add simply that, when we look at finance, we should take care also to look at the demands that we place on the health service and the changes in demand which will occur in the future. We need also to be clear that the drivers for change in the health service are not only money but also issues of accreditation and technology.

When I read the title of the debate, I tried to work out how I would describe the state of the health service. What would be the backdrop against which I would judge it? I could look at the history of the health service and see what state we are in now compared to where we used to be. However, I know that it is foolish to do

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that. One cannot look backwards, particularly in relation to healthcare, which is constantly changing. The past is, indeed, another country.

In the past few weeks, many people have suggested that I go to look at other countries. The Caribbean has been mentioned, which is a very nice idea! In view of the number and type of statistics which have been put to me about different countries' experiences of health services, I was going to suggest to the noble Lord, Lord Biffen, for whom I have enormous sympathy, that perhaps he and I might have a field trip there together!

However, I want to look forward. If I look forward 20 years to the kind of health service which I wish to see for my children, who will then be 28 and 30 years old, I have three clear objectives for them. First, life expectancy should be the same for all, regardless of social and economic background. Secondly, regardless of where they live, they should have access to high quality healthcare, including treatment and drugs. Thirdly, they should have improved their own health, learning over the years how better to take care of themselves and, indeed, of their families.

In order to achieve those objectives, a huge investment is required. However, that involves not simply an investment in the health service. We know that life expectancy has far more to do with the kind of life that we live, the kind of work that we do, the housing that we live in and the places that we visit. We know, too, that we must be flexible in the investment that we put into the different parts of our economy. We need to be able to move money around.

In my own health authority, many people become bored when I talk about the need to move away from the crisis management, for example, of elderly people in the winter. It is too late when they end up on trolleys in our hospitals with hypothermia. In my health economy and, indeed, throughout the country, we need to be able to make sure that, by using the money creatively and wisely, elderly people do not even reach the point of arriving at hospital. That requires a whole range of services to work together.

We need to have an overview of the quality of healthcare and to be sure that we know what level of quality we have. We need also to have an overview in terms of deciding which drugs we shall use. Various drugs have been mentioned today. However, speaking from my own experience, it is incredibly difficult to know the marginal benefit of some drugs when one's public health people are very busy and are trying to give a measured view. Sometimes that view contrasts with the one put forward by the pharmaceutical industry. We need to make sure that we have an independent assessment of drugs. Most importantly, we must design our healthcare systems to improve health. I have in mind the old adage of "prevention, not cure". I hope also that those objectives will be used to measure the state of our health service.

Having set out some of my objectives for the future, I looked at where we are now. We have greater investment in the health service. In my pot of gold at my health authority, I have £20 million more than I had last year. That is a real increase. As the noble

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Baroness, Lady Hogg, said, it is true that a great deal of that will go towards increasing the amount of money paid to staff. However, I was fortunate that this winter I used no agency staff in my health authority. Only one patient was transferred away, but that was one too many.

Now I have the flexibility to move money around. I want more flexibility, just as I should like to have more money. However, I want to be able to do more in terms of working with other agencies to support the health of the people of my community. I know that we now have the Commission for Health Improvement and NICE. They support me in the job that I do in making decisions about how best to spend the money to provide the best possible care. Sometimes it is not the drugs that will provide the best care. Investment in other aspects of healthcare, in therapies of a different kind in support for people, is money better spent.

Most of all, we have the health improvement programme and that is the backdrop against which I have to design all healthcare. That means that I am able to look at the population of my health economy; to look at the areas that need support and the different kinds of people who live in my area; and target and invest in helping them to stay healthy and to be cured when they are ill. That to me is fundamentally important for the future. I do not forget the problems that we have at the present. I am well aware that we have to do a great deal, but I am very confident that if you start to project forward and work backwards, which is always my view of how best to plan, we can develop a healthcare system within the public finances that will support our people for the future.

6.00 p.m.

Lord Bell: My Lords, I too thank my noble friend Lady Cumberlege for introducing this debate and in particular I would like to thank my noble friend Lady Hogg for her brilliant contribution--even if it did contain most of what I was going to say. Nevertheless, I must admit that that I am somewhat confused. Is our National Health Service something we should cherish and regard fondly as a truly wonderful service on which we must lavish attention and support because it is so good? Or should we see it as a badly-run, bureaucratic structure which makes terrible mistakes and is constantly in need of more funding that can never be satisfied?

I am no longer clear on the matter, such are the mixed messages of the day, including those in this debate. We have all seen the headlines and they lurch from screams of "under-funding" to "another fatal mistake by the NHS". I take this opportunity to extend my sympathies to the relatives of the victims of Dr Harold Shipman, who committed such terrible crimes. I endorse the Secretary of State for Health's comments that the public should not take this one man as an example of the classic relationship between patients and doctors.

What I am clear about, however, is the great respect we attach to nurses and doctors, surgeons and consultants. Those are the people we see as having the

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power of life and death in their hands. It is a powerful attraction and a right one. It is right that we should hold them in the highest regard and expect the highest standards. I am also struck by the very low regard we seem to have for administrators and managers.

I have personally experienced the health professionals' work in both the private and the public sectors; as a child with a rare blood disease and as an adult fighting cancer. Both experiences were positive and good--after all, I am still here.

The noble Lord, Lord Chadlington, rehearsed the everyday successes of the National Health Service and while agreeing with him, I do not want to repeat them. My noble friend Lady Cumberlege is so right in saying that patients do not care about administration and structure but just wanted to be looked after. Despite that, I do not claim to be an expert on the health services--I am not a doctor, merely a patient--but I have experienced all three sectors: the public, the private and the voluntary. As regards the latter, I am a trustee of Bacup Living with Cancer, as is the noble Lord, Lord Clement-Jones, who spoke earlier today--a rather odd Liberal Democrat and Conservative partnership. There are also the innumerable fundraising campaigns that I have helped to run for many charities all designed to help people with health problems. I have seen the private and the public sectors working happily and effectively together. The question in my mind is why the Government cannot see those sectors working together and think all solutions to healthcare lie in more work and money for the National Health Service.

Yes, the National Health Service is the focus of political debate, but I do not believe that any discussion on the National Health Service, or healthcare for that matter, can be constructive if it is driven by political ideology. The NHS is about saving lives and improving the quality of life. It is far too serious an issue to be at the mercy of political persuasions and pandering.

I wish to raise four points about healthcare today and I hope that at the end of it at least some of your Lordships will be convinced, if you are not already, by the point made by the noble Baroness, Lady Cumberlege, that the NHS should be left to be run by the health professionals. That should be done in as financially supportive environment as is possible, taking great support from the other two providers of our nation's healthcare services--the private and the voluntary sectors--and not under-selling or over-promoting any of them. Only then will we have a chance of delivering to the British people what they want and are entitled to--first-class healthcare.

First, the Labour Party claims that it has a monopoly on caring and that that is what makes it the best steward of the National Health Service. Further, it claims also that the Conservative do not care. That is patent nonsense and narrows the debate to a party argument instead of a constructive discussion.

My company employs 600 people. We provide private health insurance for all our employees and that insurance can be used also for the immediate family.

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We also contract two general practitioners and pay for any member of staff requiring their services urgently. Additionally, we often cover the expenses for treatments that have become a part of everyday life; be they alternative therapies, addiction clinics, counselling or care for those suffering personal tragedies or misfortunes. We extend that care through the very real community which is our workforce. We are, I feel, a truly caring and compassionate employer, the like of which should be actively encouraged by any government, and I am a Conservative.

Would it be too large a dose of common sense to suggest that the smallest of measures--perhaps the removal or reduction of tax on private health insurance--might go a long way towards encouraging other businesses to behave like mine and take their employee's health provision into their own hands, particularly small businesses in our enterprise economy, in much the same way as the Government encourage the elderly to provide for their long-term care? Would that not reduce the burden on the NHS and enable it to offer more care to people in need? Of course it would. Private insurance does not cover every need but private and public partnership does.

As my right honourable friend the Leader of the Opposition said last week, over the first 1000 days of New Labour, each day an extra 264 people joined the waiting list to see a hospital consultant. A perfectly predictable outbreak of flu became an epidemic, or at least a half an epidemic, according the noble Lord, Lord Hunt, at Question Time a week or so ago. That outbreak threatened to overwhelm the NHS despite the large numbers of people who looked after themselves.

Obviously the NHS does have a problem and it needs a solution. The Labour Party's caring for the NHS helps it to win elections--but it should not. Certainly it played politics with health in 1997 when it used the phrase "24 hours to save the NHS". It was not true then and is not true now. The NHS is not any better, as Labour promised it would be.

The winter crisis gave people their first real opportunity to judge this Government's stewardship of the NHS--they could judge both word and deed. What they heard were all too many words and what they got were all too few deeds.

Secondly, the Labour Party is completely wrong when it labels members of the Conservative Party as extremists because, it alleges, they want to privatise the National Health Service. We do not and have never wanted to privatise the National Health Service and I thought my noble friend Lady Hogg made that very clear in expressing the view of the previous government.

What the Conservatives want to do is apply common sense policies to the NHS to make it better and not to allow stubborn ideology to stand in the way of the commonsense and practical solutions that will work. It must be right to encourage the traditional three-way health partnership and so drive up standards of care. It must be right to encourage the voluntary sector that provides so much--the Red

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Cross, St John's Ambulance, medical research, cancer nurses, hospital car services, leagues of friends, major fund-raising initiatives for hospitals and so on. For example, tax relief on donations to medical charities would be no bad idea. It is not yet Conservative policy, but I shall keep trying.

It must right to allow the professionals in doctors' surgeries and clinics in hospitals to take decisions about how to deliver a strong healthcare system, based on medical need and not political priority; to provide them with the funds and not to tell them how to do their jobs.

It must be right to use the resources of the private sector in a real public-private partnership with the NHS. We do so already and we do in almost every other public service in Britain today; namely, in transport, in education and even in welfare.

Such ideas are not extreme, but Labour's policy is. Labour wants to deny the independent sector any role in making the health service better. It thinks it is better to leave intensive care beds in independent hospitals empty than to save lives. Labour wants all decisions taken in Whitehall by politicians. Total national ownership and management has been discredited for so many years but that does not stop it being Labour's recipe for modernising the health service.

Its recipe for modernisation involves dismissing the private sector and ignoring the voluntary one. What we really need to do is to use every means we can to lever new energy and support into all three parts: public, independent and voluntary. I am not saying that we can take the politics out of health but surely we can rid it of ideology. For the Government those sectors are in competition not complementary. For them, choice is an enemy to be fought rather than a friend to be embraced. People support all three sectors with money and commitment. They should all be listened to because they are all citizens. The private sector is so much bigger than is generally recognised. It is not just a question of healthcare insurance, private appointments and independent hospitals, it also embraces the whole area of self-medication, the advice of chemists and the complete range of health-promotion activity developed by the private sector.

Millions of pounds are spent every year encouraging prevention and cure, not to mention the private sector's vital research in the development and manufacture of drugs and medical equipment. Any mention of private sector partnership is dismissed as a sinister plot to privatise the NHS; it is not. The Government should recognise that. NHS Direct is a sensible and modern initiative and should be welcomed.

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