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The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath): My Lords, this has been a fascinating debate. I begin by offering my congratulations to the noble Baroness, Lady Cumberlege, on her initiative in securing it. She brings to this House enormous experience of the NHS. Working with her in the past was a great pleasure for me. I am glad to be able to debate with the noble Baroness once again these important issues relating to the future of our National Health Service. I also acknowledge the contribution made by so many noble Lords to our discussions about the state of the NHS. I assure the noble Lord, Lord Astor, that I welcome the spotlight being placed on the NHS and on the Government's stewardship of it.

At the heart of the debate is the sustainability of the National Health Service. The noble Baroness, Lady Cumberlege, has returned to a theme that she developed in a debate on the NHS in this House a year ago. She, the noble Earl, Lord Howe, the noble Baroness, Lady Sharp, and others have posed questions about the ability of the NHS to continue to provide an all-embracing service, faced as it is with so many new pressures, given the pace of medical science and technological advances and as the genetic revolution comes upon us.

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The answer must be in the affirmative. I want to make the Government's commitment to the NHS and the case for the sustainability of a tax-funded system available on the basis of need alone.

There is a terrible danger in over-emphasising the problems that the service faces. That is not a political point; it is one to which I held when the noble Baroness, Lady Cumberlege, was a Minister. We are sometimes in danger of talking up the problems of the National Health Service and talking down its successes. I strongly agree with the noble Lord, Lord Chadlington, on that point. Also, I warmed to the noble Baroness, Lady Fookes, when she described her experiences and those of her family at the hands of the NHS.

The NHS has served the nation well for 50 years. I believe that it will continue to serve us well. Of course, the siren voices warning us that the NHS is not sustainable are not new. We have heard them over almost every decade since the NHS came into existence. Experience has shown that the NHS has faced up to the new challenges placed upon it year after year.

Of course, the changes faced by the NHS in the last century will be nothing as compared with the challenges that it will face in this century. Just as society has changed over 50 years and people have come to expect 24-hour access to personalised services, so the NHS will have to change again. And just as we want to modernise the nation as a whole, so too we need to modernise the health service to play its part in creating an enterprise economy and a fair society.

The noble Baroness, Lady Cumberlege, talked about problems. I do not pretend that the NHS does not have its challenges and problems. Nor do I deny that many noble Lords have raised important issues, with which I shall attempt to deal. But first, perhaps I may turn to my noble friend Lord Winston. It is always a pleasure to hear him speak about the National Health Service.

I say to my noble friend that we have abolished the crude internal market and the absurd notion that there should be crude competition between hospitals and between doctors and nurses. We have replaced the internal market with a partnership approach. I say to my noble friends that it is right that primary care groups should play a key role in that. I make no apology to the House for that important role. Their input is crucial. But it is not an isolated input. It is informed by national priorities. It is aided by the whole process of developing health improvement programmes at local level, pulling primary care groups into the discussions with health authorities, providers and local authorities, and the development of long-term agreements rather than short-term contracts. That is surely the best way to make judgments about the best treatments to be offered to patients. All that must be underpinned by close dialogue between general practitioners and consultants.

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It is early days for primary care groups. However, one of the most pleasing indications of how they will succeed has been the development of the closest dialogue that has been known between GPs and consultants in the lifetime of the National Health Service. But, of course, we must build on that. I accept that the noble Earl, Lord Howe, and my noble friend Lord Winston expressed concerns that there are challenges for specialised services. I can tell my noble friend and the noble Earl that we have instructed regional officers to identify those trusts and services which have previously relied on extra-contractual referral income in order to fund some specialised services activity and make sure that arrangements are in place so that services will not be destabilised.

We are still in the middle of a developmental year in terms of commissioning those services. However, we are satisfied that there is good evidence that health authorities and the regional specialised commissioning groups are getting to grips with what needs to be done. I can assure my noble friend that we shall keep a very close watch on the process. I shall always be willing to discuss with my noble friend any problems that he identifies in that area.

I now turn to some of the other issues raised. I agree with the comments of the noble Lord, Lord Crickhowell, concerning mixed-sex wards. The Government are committed to their removal over the next few years, with most being removed by the end of 2002. I know that other Members of this House are keen for us to do that.

I accept the points raised by my noble friend Lady McIntosh and the wisdom she offered in encouraging the public to make the most appropriate use of the services that we offer. That is very much underpinned by the information that we can provide to the public, and which we want to provide, about the range of treatments on offer and the challenges and pressures that the service faces.

I warmed to the support expressed by the noble Lord, Lord Addington, for exercise and sport and the improvements that they can make to the nation's health. The noble Lord leads by example. Once again, in March, he will lead us all in the BT Swimathon charity event, in which many noble Lords enjoy taking part.

The noble Baroness, Lady Fookes, was right to raise the issue of dentistry. There are problems in some parts of the country as regards people gaining access to NHS dental services. We have launched a number of new initiatives, including "phone and go" access centres, and we shall shortly be publishing a new dental strategy designed to deal with many of those problems. I agree with the noble Baroness also about the problems of waste in the use and prescribing of medicines. We are keen to encourage improvements in the way in which medicines are used and see that they are not wasted.

My noble friend Lady Whitaker raised the important issue of mental illness. My noble friend will know that our national service framework was designed to ensure that we improved the status and

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provision of mental health services. We have provided £700 million of extra investment over a three-year programme. We also recognise the need to give priority to child and adolescent mental health services.

As to immunisation, I say to the noble Lord, Lord Astor of Hever, that we shall carefully monitor what happens this winter. Both the Chief Medical Officer and the Joint Committee on Immunisation will produce recommendations on the policy to be adopted next year.

Listening to this debate, noble Lords will recognise that the NHS has been under real pressure over the past few weeks. Sadly, some patients have not received the treatment that they deserve. It is also right to record that, thanks to the dedication and hard work of NHS staff both in recent weeks and throughout months of careful planning, including contributions from local authority social services departments, the NHS has coped well with very real extra demands and pressures. This is not the story that we have read in the newspapers or heard from the myriad of commentators who have used these winter pressures as an excuse to denigrate the National Health Service. I very much agree with the comments of my noble friend Lord MacKenzie. The Herculean efforts on the part of NHS staff have had ill reward from those sections of the media who seem determined to undermine them and declare that the NHS has passed its sell-by date.

What is the reality? The Government have spent the past two years laying the foundations for modernisation, abolishing the internal market and starting the biggest hospital building programme in the history of the NHS. Of the 37 new hospitals that have been given the go-ahead, 31 are based on public/private partnership. In answer to the noble Baroness, Lady Cumberlege, and the noble Lord, Lord Biffen, we recognise the benefits of working with the private sector, particularly in the area of new developments such as the hospital modernisation programme.

We have also modernised casualty services so that every department that needs capital investment receives it. We are getting more doctors and nurses back into the NHS. I had hoped that the noble Lord, Lord Walton, would have acknowledged those efforts and the decision of the Government to increase the number of medical training places and develop three new centres of medical education. We have increased the number of nurses, not just those who have returned or are about to return, and the number of training places. Our efforts have also led to an encouraging increase in the number of young people who apply to become student nurses. The noble Viscount, Lord Bridgeman, drew attention to the necessary changes to be made to the nurse education curriculum. I accept the need to ensure that, alongside academic training, there is greater emphasis on practical training, and the debate which your Lordships had last week on this matter was very illuminating and informative.

The noble Baroness, Lady Cumberlege, warned us about the dangers of putting too much faith in structural change. Having lived through many

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structural changes in the NHS which the previous government initiated, I can only echo that warning. However, our emphasis is not on structural change for its own sake but on improvements in services, and in that we have the great support of our staff. Government and Ministers have a major role to play in developing the strategy under which the NHS should operate.

It is nai ve to believe that the funding and overall strategic direction of our great National Health Service can ever be disengaged from the parliamentary process, but within the setting of a national service, with Ministers setting national priorities, there is considerable room for local NHS organisations to grow, develop and take ownership of the policies that they wish to see brought into play. Primary care groups and trusts are the visible indication of our wish to delegate decision-making to the level nearest the patient.

We are making improvements to the National Health Service. As an example, NHS Direct is part of the process of modernisation. That is a wholly new service which provides easy access to professional advice over the telephone or on the Net. As my noble friend Lord Prys-Davies emphasised, this is the kind of innovation that we are introducing to the health service. The service is very popular with patients; over 1 million calls have been received. In answer to my noble friend Lord Rea, the University of Sheffield has undertaken an assessment of NHS Direct and found that 97 per cent of callers are satisfied with the service received. It is important that primary care has links with NHS Direct. We have set up a primary care interface group which enables us to bring representatives of primary care together with those who run NHS Direct to talk about how the service can be developed and improved.

Step by step we shall build a faster service, but it will take 10 years to modernise the NHS, not least to train and recruit the extra doctors and nurses we need. As my noble friend Lord Davies reminded us, we are on target to hit our manifesto pledge to get waiting lists down by 100,000, but that was always just the start. In answer to the noble Lord, Lord Chadlington, we are determined to act on outpatient waiting lists and will treat one third of a million more outpatients this year.

We want to modernise all aspects of treatment in the NHS. Our next step is to modernise the services which deal with the biggest killers--cancer and coronary heart disease--as well as mental health. We are providing more money to give suspected cancer patients faster treatment and provide more operations for cardiac patients. While this brings about a revolution in hospital care, to complete it we must ensure that hospital services are fully integrated with the rest of the care system.

It may be that, given all the changes that have taken place in the NHS over the past decade, many hospital clinicians have felt rather left out. We must harness more effectively the enormous contribution that hospital doctors in particular make to patient care. That must take place in the context of a modern

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healthcare system which moves away from the management of single health institutions and towards a concept where there is management of the clinical conditions that span the component NHS services from which patients receive care. That calls for an intermediate level which is fully networked into local hospital, community and primary care services.

I was interested in the contribution of the noble Lord, Lord Rotherwick. Over the past few weeks hospitals have been full of very elderly people with severe respiratory illness. Demographic trends suggest that those pressures will not change. What must change is how we deliver those services. For example, it is self-evident that we need more critical care beds. It is perhaps less evident, but no less true, that we need wholesale modernisation of the care process. In answer to the noble Baroness, Lady Thomas of Walliswood, that is one of the fundamental findings of the national beds inquiry which my right honourable friend the Secretary of State hopes to publish later this month. I am sorry that the noble Lord, Lord Clement-Jones, is not here to glean that information. The inquiry shows that in comparison with a number of other European countries the NHS is a relatively efficient user of beds with comparatively low bed numbers.

The inquiry reveals, however, that there is a wide variation in hospital bed usage between health authorities in the NHS. Interestingly, it has not shown any simple link between the number of acute beds, the management of emergencies and elective waiting times. All this points to the fact that we need to take a whole-system approach to our services. That approach, under any scenario, will require an increase in the number of beds in the system. I believe that the trend of a reduction in hospital beds over the past decade or more cannot keep pace with changing demography, additional activity and the new services that we envisage for the NHS. More on that later.

This is just the beginning. We want the whole patient experience to be transformed. Our vision is of an NHS where services are shaped around the convenience of patients, and--my noble friend Lord Harris was right--where decisions are shared between clinicians and patients.

That means embracing technology to provide faster services. It means direct booking of hospital appointments, shorter waiting times for treatment, more rehabilitation services, greater use of telemedicines, the Internet and NHS Direct to bring care closer to home. We have made a start on this vision. Now we are upping the pace of modernisation.

A number of noble Lords raised the point about what has often been described as the lottery of care, and the unacceptable variations in access to care from health authority to health authority. We are determined to end that lottery. For the first time in the history of the NHS we are setting clear national standards, through national service frameworks and the National Institute for Clinical Excellence. Perhaps I may say this to the noble Lord, Lord Forsyth. The work of NICE is not about rationing but about

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ensuring that the treatments provided in the NHS are the most effective. The work of NICE will enable us to speed up the introduction of such treatments in the future.

For the first time we are inspecting all parts of the health service, through the Commission for Health Improvement, to ensure that patients obtain the top class care they deserve. Of course--and I turn to my noble friend Lord Winston--the NHS modernisation programme needs cash. So when we look to NHS resources over the past few years it is interesting that many commentators said that the NHS needed 3 per cent growth a year to keep pace with demographic and technology changes. I say this to my noble friend Lord Winston and the noble Lord, Lord Walton. In the three years of the current Comprehensive Spending Review we have given more than that: an average of 4.9 per cent a year over the CSR period. We know that the NHS needs sustained investment. That is what it will receive. My right honourable friend the Prime Minister has said that. Indeed, as my noble friend Lady Ashton has testified, that extra money is being received by health authorities, enabling them to spend more money on developments in services. It is tempting to bandy figures with the noble Baroness, Lady Hogg. I suspect that we would not get far.

I turn to the more fundamental issues relating to future funding of the health service. The noble Lord, Lord Biffen, called for a health Select Committee. He drew attention to the various funding options on offer. Indeed, today we have heard several of those options. The noble Baroness, Lady Cumberlege, proposed a health insurance premium--essentially, I guess, a hypothecated tax. I am not convinced. Inevitably, it reduces government flexibility over public finances. I think that it is potentially more regressive.

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