rose to call attention to Her Majesty's Government's plans for the National Health Service; and to move for Papers.
My Lords, I start by declaring an interest: I chair St George's, University of London; I am a senior associate of the King's Fund; and I have other connections with the National Health Service. For most of my life, the health service has been my life. I grew up in it and, like many people in this country and in your Lordships' House, I cherish it. I welcome this debate, and am pleased that, at this critical time, so many of your Lordships have chosen to take part. I am grateful to the Minister for being here today—I know it is at some personal cost. I particularly welcome back the right reverend Prelate the Bishop of Portsmouth and look forward to what he will tell us.
The health service is an icon of Britishness, like wet summer holidays in Blackpool, garden vegetables and the man from the Pru. Yet Britain has moved on and the NHS has not. The delight of the NHS is that it was founded upon Christian Socialist ideals. It was a co-operative in the age when the co-op sent MPs to Parliament. Following in the steps of the mutual societies, it is a state mutual society—each according to their needs. The NHS arose out of two great wars, when the state ruled and we ate healthy food in rationed amounts. Times change, and in a consumerist society that ethic of mutuality no longer works. A cancer sufferer feels entitled to every chance of life that they can grab, regardless of cost. Others may lose out, but they must fight their own corner.
That is a radical change; the foundations of the NHS are being eroded and we have to find a new ethic. The Labour Party has always considered that it has a head start with the NHS, because it perceived itself to be guardian of a socialist ethic. New Labour is not socialist and has no discernable ethic. The NHS needs one badly. This House is admirably suited to the job of replacing the philosophy of Beveridge with a new one, acceptable for today's society, and we should set about that task now. In the 1990s, we made a start in adapting the ethos of the NHS to reflect the change to a consumerist society, without losing its founding principles. In 1997, this change was swept away. Billions of wasted pounds and nine years later, the Government are trying to regain the position that they so carelessly threw away on arrival.
I should like to explain. Up to two or three years ago I could, like any other working person, visit my GP at an evening or weekend surgery. That has gone. It went because of botched negotiations of the new GP contract. Now, in an extraordinary realisation of the obvious, the recent White Paper, Our Health, our care, our say, without a hint of humility, states:
"we will introduce incentives . . . to offer opening times and convenient appointments which respond to the needs of patients".
So the Government paid GPs to close down and now it pays them again to open up. That is not good management.
I acknowledge that managing the NHS is not easy. There are, and always have been, two contrary forces pulling at the health service—local management and central control—but to veer from one to the other is simply crass.
When the Government came to power, they inherited eight regional offices. Four years later, they were abolished in favour of four regional directorates. The directorates lasted just one year and were replaced by 28 strategic health authorities. The strategic health authorities now face the chop and are to be merged into about 10—almost the old regions back again. GP fundholding was scrapped and, nine years later, practice-based commissioning is to be put in its place. In 1997, the internal market had to go, to be replaced last year by payment by results. Here, policies could have been marginally adapted to achieve the same ends. Adaption is cheap but, of course, politically less heroic. This is about political egos versus good management.
In 1998, 100 health authorities were abolished and primary care groups formed. They were swept away in favour of 303 primary care trusts. Established just three years ago, these trusts are now to be merged into about 130. Their staff are expected to implement the huge changes in the White Paper while they are worried stiff about their jobs, mortgages and schools for their children.
In June, the PCTs were told to divest themselves of services such as district nursing, but in October the Secretary of State told them that that was not her plan. The Health Select Committee commented:
"The Government's numerous announcements and subsequent retractions mean that it is still unclear what its policy is".
The committee goes on to describe the Government's approach as "clumsy and cavalier", and states that PCT reform has,
"produced a flawed and incoherent policy that is ill judged in the extreme".
That is strong language for a Select Committee with a Labour chair and majority. The chairman of Basildon PCT told the committee:
"some staff have had different employer names on their payslips five times in ten years".
However, that is by no means all. Ministers have a penchant for agencies. Agencies are set up, as was the National Care Standards Agency, where all staff were recruited only for it to be abolished 14 days later in favour of another agency, the Commission for Social Care Inspection, which, in its turn, is to be amalgamated in 2008. We have seen the establishment of the NHS University and its demise. The Leadership Centre, the Modernisation Agency, the National Clinical Assessment Authority, the Commission for Health Inspection and the Commission for Patient and Public Involvement have all been here one minute and gone the next. The National Institute for Clinical Excellence, a great survivor, necessary and admirable, is supposedly independent but is now being undermined by a panicked Secretary of State who feels moved to start prescribing herself.
Round and round we go, with managers and staff so dizzy that they fall off the carousel. Their falls cause injuries. They are not well looked after. The Christian Socialist ethic has been replaced by fear and recrimination. As the Select Committee said,
"this approach to NHS staff has had a very damaging effect on staff morale".
This is a nine-year chapter of bad management, which no commercial organisation could possibly survive. The Opposition have been patient. We have waited, and we have hoped that the extra money we welcomed will be well spent. Now we can no longer keep quiet. The top ministerial management is an embarrassment. It is hardly surprising that expenditure on the NHS has doubled in the face of all these changes and, according to the Office for National Statistics, there has been a less than 2 per cent increase in productivity. That is not bad; by any management criteria, it is a disgrace. It seems that just because the British public are compulsory subscribers, the Government have taken this as a writ to mismanage stupendously. Nicholas Timmins, the public policy editor of the Financial Times describes this expenditure bonanza as an opportunity squandered.
Looking to the future, the Government have recently published a framework document for 2006–07 which bears little relationship to the White Paper. It tells us that 20 per cent of practices will be involved in practice-based commissioning by the end of this month. Really? They have hardly started. It also tells us that it will be 100 per cent within a year. I doubt it. With one or two exceptions, the Government have not managed to get clinical engagement. In lay language, the doctors do not want it. They are reluctant because they know the infrastructure is not there to support them. Computer systems are in their infancy and prone to break down. When I was a Minister, there were two consecutive years without a single case of home-grown measles. Not only have the Government been responsible for the debacle with the MMR vaccine, but the health of thousands of children is now being put at risk by significant failures in the new £6 billion NHS computer system. The system was imposed on primary care trusts and has destroyed 22 years of perfect record-keeping. As a community paediatrician told the Times:
"The system is so bad, it's my opinion it will never work, but the department has spent so much, it's unwilling to go back and start again".
When the internal market was scrapped in 1997, a gap was left in financial management. To fill this hole, payment by results—a tariff system for contracting services—was introduced. This is not small beer. By the end of this month, the total amount involved will be £9 billion, and in a year's time it will be £22 billion, or a third of the whole NHS budget. But one month before the start of the new financial year, the Department of Health finds that its figures are wrong. The tariff is withdrawn, and every finance director is left with months of worthless financial calculations, so no wonder there are expletives flying about.
If management changes are irresponsible, managing the doctors of tomorrow is worse. Britain has a formidable reputation for medical training, not least because we have an enviable record in research and senior consultants with world reputations. It is good to see the Prime Minister, in his foreword to the White Paper, wanting,
"change to be driven, not centrally, but . . . by the people who use services and by the professionals who provide them".
Contrast this with the letter in last Saturday's Times from 86 of our most senior doctors, angry that they are not trusted even to select their junior medical staff. They write:
"How is it conceivable that an untested computer programme should replace selection processes carefully developed by dedicated professionals over many years?".
How many of us would choose a secretary by computer? We would want to meet the applicants and assess their strengths and weaknesses. The computer system is not management. It is number selection, fit only for the lottery and hurtful to consultants. If the Prime Minister wants the professionals to be in charge, this is hardly the way to trust them. If Ministers decide that computers should choose medical teams, Ministers must take the rap when things go wrong. Patient safety should override ministerial whim and, as chair of an outstanding medical school, I think that the future of young doctors should not be decided by a machine, particularly in a profession where human contact is so highly prized.
The Royal College of Physicians has undertaken a review of professionalism—professionalism in 2006, not an archaic view. It has taken 15 months and I have had the privilege of chairing it. There was no froth, no spin and no crisis. It was a solid piece of work laying new foundations for the care of people's health, which is absolutely dependent on patients trusting their doctors. All the time that this review has been going on, the management of the NHS has been going on as well. The ministerial team has displayed all those qualities that a doctor should not show—vacillation, uncertainty, misdiagnosis and capricious changes in medication—which is impacting on doctors as they plod on trying to deliver a service through a hail of bullet points aimed at obscured targets.
It is of huge concern that the management is now degenerating into a farce. Five years ago the chief executive of the NHS and the permanent secretary posts were amalgamated. Now they are to be split again, and I am very sad that Sir Nigel Crisp is the casualty of ministerial whim. He is a man of integrity and has given some stability in a department of ever changing ministerial teams. I am delighted that he is to come to this House and I am sure that he will be a contentious contributor.
What we need now is a two-year moratorium on management change, a time for thought and reflection, intense debate, and a search for a world-beating team to restore the NHS to a world-beating service. I would ask that the first and instant result from this debate is the immediate cessation of the system of selecting junior doctors, for that is endangering lives, and that those 86 very senior and very sensible consultants who wrote to the Times should be shown respect. I beg to move for Papers.
My Lords, this is not the first time that we are indebted to the noble Baroness, Lady Cumberlege, for giving us the opportunity to debate the NHS, an issue so close to the hearts of many of us. Today, I must congratulate the noble Baroness particularly on the magnificence of her timing. Her contribution to the NHS is well known and much appreciated, although, following her remarks, perhaps I may remind her just how many changes her government presided over in the NHS during the 1980s and 1990s.
This is not the first time that I do not find myself in entire agreement with the noble Baroness's views on the NHS—comparisons of glasses half full or half empty spring to mind. My view of the NHS is definitely of the more-than-half-full kind. I will declare my interests and my reasons for that. I have been employed by the NHS. I have worked very closely with it in various occupations for 40 years. I have always been an NHS patient, will never be anything else and, most particularly, I owe my life to it. The dedication, skill, commitment and willingness to take risks of NHS doctors, nurses and associated professions saved my life when all hope of saving it was lost. So your Lordships will not be surprised to know that I am a huge fan. I am, I know, not alone in that, either in this House or in the public at large. But that is one of the paradoxes which always face us when we discuss the NHS. It is my belief and understanding that the experience of most people with the NHS is good and getting better.
Only last week I talked to a friend who had had symptoms which required her to have a colonoscopy. She said: "As soon as I saw my GP, it all swung into action. I saw a specialist in a week, had a polyp removed there and then, and I am now on the list for a colonoscopy every two years. I know that's very unusual and that I was very lucky". No, it is not unusual and she was not lucky. Yet such is the negative publicity that we hear all around and such are the scare stories put out by the media, that people think that their good experiences are unique and that they were lucky. Quite the opposite is more likely to be true: far from being the norm, it is unusual and unlucky to have a bad experience. The massive investment made by this Government and the reduction in waiting times and waiting lists, together with a much greater emphasis on patient and public involvement, have clearly made the NHS better, however difficult it is for other political parties to admit.
The scorn poured on the so-called "waste" of these huge investments, which have resulted in 60,000 more nurses and 30,000 more doctors, is not appropriate and I would never question the ethics of those doctors and nurses. Neither should scorn be poured on the huge hospital building programme and the investment in so many new services, such as local walk-in centres and NHS Direct, which is so widely used. We should also note that anyone who has recently used the NHS cannot possibly have failed to notice how different the focus on the patient's needs and wishes is now from how it used to be.
Today's debate is about plans for the NHS and in the rest of my remarks I want to concentrate on the proposals outlined in the White Paper Our health, our care, our way, with particular emphasis on the effect of the proposed reforms on those who are by far the biggest providers of health and social care in our society—the unpaid, so-called "informal" carers: your family, your friends and your neighbours.
For carers, as indeed for many people, there have always been two major problems with the way healthcare is provided. The first is that there has been far too much emphasis on hospitals, or what we now term secondary care, when most people's experience of the NHS has nothing whatever to do with hospitals—it occurs in their local community, via their GP and their local primary care practice. The emphasis in the White Paper on choice about the GP with whom one registers will change the way in which surgeries operate. Surgeries should be open at times to suit the individual and his or her family, not the convenience of the practice manager. Furthermore, practice-based commissioning will lead to health services being developed which are not only of high quality but close to your home. That is important to everbody, but it is particularly important to carers, who often have limited time to take their relatives from place to place. Moreover, respite care is not available unless it is provided close to home or in the home itself. Being able to plan in advance—especially for those carers continuing in paid employment—is very significant. This will mean that the increased ability to plan treatments ahead and in a way which suits the patients and carer—not just the provider—is especially valuable, notwithstanding the teething problems with some computerised systems.
The second issue that carers have always struggled with is the lack of proper co-ordination between health and social care. Your Lordships will be familiar with the "Berlin Wall" terminology that we have often used, and complaints about professionals not passing on proper information. When I was working full-time for carers I lost track of the number of times a carer would say something like, "What I don't understand is how they all fit together. Why didn't social services know that Mum was being discharged and have it all organised in good time? Don't they ever speak to each other?"
This has undoubtedly improved tremendously in recent years, as social care has been given more emphasis and as pooled budgets and better discharge procedures have become more common. But there is still a feeling that social care is in a sense the poor relation, instead of being an integral part of the care that people need. That is why the emphasis on setting national standards for social care and addressing workforce issues, including setting up the General Social Care Council—I declare an interest as its inaugural chair—has been so significant in raising the profile of social care and its standards.
Most people, especially those with long-term conditions, want to remain in their own homes as long as possible. The only way to do this is to ensure that we have fully integrated health and social care services so that vulnerable people—either patient or carer—do not fall through the gaps. The emphasis on this in the White Paper is very welcome. In the case of carers, it makes very sound economic good sense to provide services which enable them to remain in work for as long as possible, and I am glad that the White Paper recognises this. Nor should we forget that carers themselves will be a drain on the NHS if we do not properly support them since carers are twice as likely to suffer ill health, either physical or mental, as a result of caring.
Carers UK recognises that the White Paper addresses several of the key recommendations for which it has been repeatedly calling and that the proposed reforms go a considerable way to recognising the support needed by carers as they are such a vital part of our nation's health and social care system. Provided they are backed up by the necessary resources—the Minister will be familiar with the chilling statistic that by 2037 we will need an additional 3 million carers to care for the rising numbers of older and disabled people if services do not improve—these proposals for reform will be most welcome and will continue the improvements in the NHS which all in this House and outside should be willing to celebrate.
My Lords, there is a saying that health is not valued until sickness comes, and that has certainly been my experience over the past six months, whether the word "health" means my own health or it means the health service. This debate is timely and I thank the noble Baroness for arranging it, and for her kind words, because if my calculations are correct, while the Minister was celebrating the anniversary of his arrival on this planet on
I am aware that this is rightly a very technical debate. The fates have decreed that it comes when the National Health Service has entered the very forefront of public concern this week. As someone who could be described as a consumer rather than a professional, I want to confine my remarks to three areas: co-ordination, choice and stability. First, I turn to co-ordination. One of the issues arguably facing the NHS is continual reorganisation. Of course organisations sometimes need to be reorganised, but I have to say that the current plans to reorganise the PCTs—I live in the thick of one of those: Fareham, which has overspent considerably—could not be worse timed. I say that in the light of the recently announced plans to reorganise local government. Surely the cart is before the horse, or whatever image comes to mind.
The balance is always between micro- and macro- management, but both are needed and it is a question of collective agreement and long-term policy about where each properly lies. The current plans have been severely criticised by the House of Commons Health Committee both because they come only three years after the previous reorganisation and because they are likely to set National Health Service organisations back by 18 months, with adverse effects on patient services. As a recently discharged patient, and I want to assure noble Lords that there are no special episcopal perks in the NHS aside from the odd joke, I want to be reassured that this will not be the case—and not just for acute treatment, but for other more day-to-day, non life-threatening programmes. I am concerned, for example, that drastically imposed economies on such apparently small, but for patients and their families highly significant issues as parking charges, do not get imposed. We were lucky in that respect.
I do not want to labour the point unduly, but one of the most important keys to the well-being of a society is how it treats its most vulnerable people. Over the 10 years that I have been Bishop of Portsmouth, I have watched the Haslar hospital saga, and the growing consensus on the PFI at the Queen Alexandra hospital. While I have to say that the planned eventual closure of Haslar is not good news for Gosport—and I do try to keep the big picture in front of me—far too often one of the subtexts of the PFI plan seemed to paint a fanciful picture of a new building with plenty of land around and unlimited parking space, surrounded by a motorway ring road with easy access for all and sundry, including from the Isle of Wight, which is manifestly far from the case. Co-ordination means many things, from ensuring that patients do not suffer from casual or long-term economies to an adequate transport system—I am thinking of natal units as well as emergency cardiac treatment.
Secondly, there is the issue of choice. I am afraid that the shibboleth about choice needs a bit of debunking. I am not against choice. I am glad that there was an array of newspapers in the service station on the M3 this morning. But when, after a gruelling weekend of three big services in unusually hot weather at the end of August last year, I realised that I needed to see my GP, I am glad that I was able to do so on that Monday morning and quickly. That is what people want. I would have gone in the evening if I had had to do so, but at least I got there.
If I may speak for the church community with regard to consumerism, I was grateful to receive communion on Sunday mornings from whatever chaplain was available, regardless of denomination, and the form of service was not something about which I was prepared to grumble—especially during chemotherapy—or even write a letter to the local bishop, as that would be me. Moreover, I know that there are growing concerns among doctors, both general practitioners and those who work in hospitals, and among nurses, about the long-term effect of the rhetoric of choice on ordinary people's expectations. I am sure that this has played a part in the attacks on nurses that received national news coverage recently. Choice, whether we like it or not, is part of contemporary culture, and I echo the words of the noble Baroness. Perhaps the kind of reflective and more wisdom-based rather than technocratic changes that are needed should try to shift the language of public debate more in the direction of manageable, limited outcomes, in order to prevent an increasing outbreak of false expectations. Choice in healthcare may be relevant to some elective surgery, short-term treatments or diagnostic procedures, but it is far less appropriate for life-threatening or chronic conditions. When I was diagnosed, I did not want or need choice. What I needed and got was the security of immediate care, which in all its respects gave me the confidence to keep going, especially in those difficult early weeks.
Thirdly, there is the issue of stability, by which I do not mean, "Stop the world, I want to get off" and nor do I mean no change—far from it. However, all organisations need a collective culture that builds up a sense of identity, with loyalty and allegiance as essential parts of its well-being. Charles Swinburne, the 19th-century writer, may have been in one of his sharper moments when he wrote:
"Body and spirit are twins; God only knows which is which".
Part of any care organisation involves attending to both, however defined, religiously or not. There are inevitable positive spin-offs not only for the patient but for the whole ward.
I do not envy a Labour Government having to face up to what is happening to one of their most precious jewels with which I grew up. There is a collective desire to get out of the mess. Briefly, I want to offer some advice from my work. If I want to set in motion a diocesan initiative, I know that I must convince a lay reader up the Meon valley, a church warden in inner urban Portsmouth and a country vicar in rural west Wight. I know that their first two questions to me will be: how does this initiative relate to the last one in addressing its weaknesses and building on its strengths; and how will it change things for the better on my patch?
My Lords, I, too, thank the noble Baroness, Lady Cumberlege, for securing this debate and for encouraging those of us on this side of the House to return to our socialist roots. I believe that Nye Bevan would be turning in his grave with pleasure at the thought of the investment that has been put into the National Health Service by this enlightened Government over the past eight years. However, I want not simply to make a paean of praise, but to raise certain concerns. In doing so, I declare that I am president of the Parkinson's Disease Society in Chester, where we are very concerned, as are Parkinson's sufferers throughout the land, at the threat to PDS nurse specialists. They play a vital role in helping Parkinson's sufferers, and I hope and believe that the Minister will take that issue up.
The Minister will also be aware of the importance of the medication regime. If it is disrupted for a Parkinson's sufferer, there is a problem controlling symptoms. I hope that he will lend his support to the Parkinson's Disease Society's "Get It On Time" campaign, which seeks to establish effective medicine-management systems, to ensure that Parkinson's patients get medication on time every time. I also alert him to my experience of dispensing pharmacies, which tell me that in certain areas they are having difficulties securing vital medicines from suppliers. In my area, Lantus insulin and metformin tablets, to help and treat people with diabetes types 1 and 2, are in short supply, with all the threats associated with that.
It has been established that two out of five Parkinson's sufferers are unhappy with palliative care and believe that access to that care worsens as the disease advances. I hope too that the Minister will ensure that quality requirement No. 9 of the NSF for Long-term Conditions is applied rigorously. I share the concern of my noble friend Lady Pitkeathley about carers for Parkinson's. They play such a vital role in stabilising the lives of sufferers that I hope they are truly recognised by this Government, as I am sure they are. Finally on Parkinson's, I ask the Minister why free prescriptions are not accorded to Parkinson's sufferers, many of whom are below retirement age.
I return to diabetes. I very much welcome the January 2006 White Paper, Our health, our care, our say. Proposals such as life checks, information prescriptions and personal care plans are good news for diabetics, who value the ability to manage their lives—and gain self-esteem thereby—as well as to be economically active. However, I ask my noble friend why there is a lack of clarification about the additional resources that must be attached to the very laudable plans enshrined in the White Paper. Does he recognise that changes in the NHS such as practice-based commissioning, payment by results and the shifting of care from hospitals to the community will have significant implications, and will he ensure that we do not have fragmentation of services?
My final question on diabetes is a more general one about the money that has gone into the National Health Service, which is good and very welcome. However, the Government are setting a high priority on spending money wisely. I therefore ask the Minister to look at certain schemes—I gave him notice of one of them before the debate—in which I fear that money saved in the short term might be lost in the long term. The case to which I refer is that his department is commissioning research into commercial blood-sugar test equipment, and I hope that he is not guided simply by getting the lowest price. The best equipment also has attached to it a good after-sales service, to make sure that it is tailor-made to patients. I give the example of two blind diabetics, for whom there was a capability of making a speaking monitor to give their blood-sugar results, thereby enabling them to remain at home and to lead active lives. They were therefore not always having to visit their GP or local hospital to make sure that their diabetes was properly under control.
The second example is the laudable initiative by the Government to eliminate the number of missed appointments by patients at hospitals, which wastes money enormously. The Government have recognised the problem but I ask them please to ensure that those who might be struck off the list are properly advised and that that is not done without proper reference as to why they missed the appointments.
Finally under this heading, it has been brought to my notice that money is sometimes wastefully expended. For instance, in the chiropody services, in the wake of the BSE outbreak, all equipment is being sterilised, regardless of whether procedures are invasive or not. Indeed, it has been computed in one PCT area that as much as £200,000 is spent on sterilisation of the appropriate equipment, but needlessly so. I hope that the Minister can turn his attention to that.
My final remarks are about the European Union and the failure of how we deliver our health services and share best medical practice across the Union. I am fearful that we do not do enough of that and learn from the comparisons that we might make with fellow countries. I have in mind, for instance, France, where, yes, more money is spent on the health service as a proportion of GDP, but a good health service results. That means a healthy population and, therefore, an active economy. For instance, women are tested for breast cancer from 45 onwards, men for prostate cancer from 50 onwards and a general test is given to people from 46 onwards, thereby catching diseases early and enabling appropriate medication to be given. I believe that HMG are moving towards that, for instance with the proposals for life tests.
One final point, which I am sure no one else will make in the House today, is that it would be encouraging if our medical professionals were given the proper language training within the European Union, so that they could converse and ensure the transaction of ideas. Ultimately, that would enable the benefit for all patients and practitioners to be spread more effectively throughout the United Kingdom and, indeed, the European Union.
My Lords, it is a pleasure to follow the noble Lord and particularly to congratulate my noble friend Lady Cumberlege on securing this debate, which could not have been better timed. I praise not just her speech, which was exceptional, but her dedicated interest in healthcare over the years.
When I was Secretary of State for Health, my noble friend was one of my health authority chairmen, before she went on to higher and bigger things. That is rather different from the noble Lord, Lord Warner, who was previously a distinguished civil servant at the Department of Health. When I became Secretary of State and arrived at Elephant and Castle, he promptly handed in his cards and moved away. So there we are.
I have three swift points to make. The first is to pinpoint a puzzle about the present-day health service. There is no doubt that the Government are spending more on the health service. I say that with a certain amount of envy, because I once did a waiting list initiative on £25 million. However, the real test is whether the extra resources are being used to best effect. If, for example, you spend a disproportionate amount on pay increases, the benefit to patient services is limited.
What seems to be beyond doubt is that the public themselves do not always believe that the money is reaching the services. I saw a poll last week which asked whether people thought that the quality of the National Health Service had improved; 23 per cent said yes and 77 per cent said no. I recognise, as the noble Baroness, Lady Pitkeathley, pointed out, that when people are asked about their personal experience, those results are undoubtedly different, but that has always been the case—it was my defence when I was Secretary of State for Health.
Add public concern to the big financial deficit and the resignation of Sir Nigel Crisp—to the discomfort of Ministers—and the press are writing not about success but about crisis in the health service. Perhaps the lesson here is that, whatever else, good management is of the essence in the health service. I remember that when I introduced general managers into the health service, it was fiercely opposed. My opponents said, "We do not want to see the health service run like Tesco". I am tempted to say, "If only", because the health service is like any other big organisation—it needs strong and skilled management locally and nationally.
It always seemed to me, and seems to me particularly today, that at the centre one of the obstacles to good management—perhaps this lies behind the demise of Sir Nigel Crisp—is that there are far too many people intervening and double-guessing. Ministers, civil servants and politicians may sign up to the general proposition of moving resources north, but not if it affects their own area. I see also that the Prime Minister now has his own No. 10 health adviser. Why does the Prime Minister need his own health adviser? Surely his adviser is the health secretary. That was certainly my view when a similar proposition was put to me. If you go the other way, people do not know to whom they are answering. It blurs the lines of responsibility and is certainly not good management.
As I went on in the health service, my view became that we would be better served if we could in some way separate policy development—properly the function of the Department of Health—from implementation and management of the service. My concept was for a health commission managing the service at arm's length from government, accountable to government but not run by it. I remember putting that to my noble friend Lady Thatcher. She thought for a little and then said, "No, they would say this was just a prelude to privatising it". There was no doubt that, at the time, that was exactly what would have been said, although I now note that the idea has the support of organisations such as the King's Fund.
That brings me to my second point. No issue is more bedevilled by party politics than the health service. In my view nothing has done more harm over the years and stood more in the way of progress than that. I remember in 1983 publishing a circular entitled, Co-operation between the NHS and the private sector at district level—not exactly a threatening title. The idea was that, to reduce waiting lists, health service patients should have the opportunity of treatment in private hospitals, and health authorities should explore the potential of placing contracts with private nursing homes. That was described by Michael Foot as,
"the most serious attack on the National Health Service since it was originally started".
I am delighted that 20 years later it is now a mainstream policy of this Government. They rightly support co-operation between the private and voluntary sectors, because what matters is not what badge is being worn by the provider of healthcare but the quality and cost-effectiveness of that healthcare. Many people—some with vested interests—will snipe at that policy of co-operation, but I hope very much that the Government persist with it. In passing, I congratulate David Cameron on making it crystal clear that this party is not interested in introducing some new form of insurance system but is intent on developing the National Health Service. I hope therefore that there will be an end to all this nonsense about privatising the health service.
My last point concerns an area where there is no doubt that the service has gone backwards—sexual health. We should remember that the sexual health clinics—the GUM clinics—pre-dated the National Health Service. They came out of a royal commission in the First World War and their purpose and achievement was to provide a free, anonymous walk-in service. Their justification was not just to help the individual, but to prevent the spread of disease. Today, 60 years after the inception of the National Health Service, we have delays before patients can be seen, and we have crowded waiting rooms and run-down premises.
I am a trustee of the Terrence Higgins Trust, which, together with a number of other organisations, has just carried out a survey of provision, of which one section was devoted to the views of clinicians. I shall give one extract from it. The clinicians were asked:
"Are HIV and sexual health sufficiently prioritised within your local health services?"
Nineteen per cent said yes and 73 per cent said no. Yet we are in a position where sexually transmitted infections, including HIV, are the greatest infectious disease problem in the United Kingdom today: 1.5 million new episodes are seen in sexual disease clinics, over 60,000 people are living with HIV, and chlamydia is doing a great deal of damage, particularly to young women.
Here you can correctly talk of crisis, for not only is our treatment falling short, but our prevention effort has been inadequate over the past 10 years. This is not a fashionable subject; politicians tend to be embarrassed by it or to avoid it. Something like HIV/AIDS does not come high up in the usual list of public concerns, yet it is a disease like other diseases, which is causing real damage to thousands of people. One test of the National Health Service is whether it deals with such challenges. I fear at present that this challenge has not been met. I urge the Government to put new energy and new purpose into bringing help here.
My Lords, I add my thanks to the noble Baroness, Lady Cumberlege, for the debate, not least because I agree with much of what she said. I also send a metaphorical hug across the Chamber to the noble Lord, Lord Fowler, for his words about the way that the NHS is now and should be perceived. I thank him very much, and much of what I say will echo his words.
I have been in the health service now for 42 years. Now noble Lords are all looking at me wondering how old I am. I was an auxiliary nurse at Nottingham General Hospital before going to medical school. My first job was on John Player ward for respiratory diseases, where one of my jobs was to polish the brass ashtrays twice a week. So to anyone who thinks that the health service has not moved on—we have. I now have to visit several hospitals where I used to work as a houseman, notably Whipps Cross Hospital in east London. Anyone who thinks that the health service has not changed should come and see the difference. It has four times the amount of staff, and it has better qualified nurses and doctors than it ever had before. I had to work for a drunken consultant who was never there at night, struggling with an unqualified registrar to do surgical operations. That was in 1971. Frankly, the NHS has changed.
Now I have moved on. I have been a clinical doctor and an academic for 25 years. I then became the chairman of a trust, the chairman of a health authority, and now I am in the stratosphere of the strategic health authorities. To me, that is a step too far for the next reorganisation. I have been through five of them; I am not going through another. The NHS cannot go on as it is. It has had a vast improvement in finances, which has been very welcome. In east London, we have had a 30 per cent uplift, which is the biggest uplift of any strategic health authority area. It was much needed in the areas that we serve, which have a diverse, impoverished population with very poor health records. There have been dramatic improvements in performance to targets; if you give us targets we will meet them. We always deliver the targets eventually. But patients are telling us that what they get from a rather mixed primary care service that is inadequate for the local population is not that much better. The patient experience has not improved enough in our poorest areas; there is still an attitude that people should be grateful for what they get.
The noble Lord, Lord Fowler, referred—in other words—to the NHS as being a bit like a political football. But I remind your Lordships that, with a few hiccups, the broad thrust of the global forces of policy movement has been driven in the same direction. Conservative governments and now the Labour Government have moved quite a long way towards trying to separate out and introduce plurality of provision into hospitals, primary care and community services. To my mind that has been very much for the better. Self-governing trusts were the first thrust—they did not quite get there because we lost the bottle—and foundation trusts and foundation services introducing plurality of provision are the next, similar approach.
Yet again, I am afraid, I see a lack of political bottle to see it through. You cannot introduce plurality of providers without recognising the need for a failure regime for those who cannot perform. We have some superb managers in the health service—I have worked in the independent sector and I know very well that we do not lack good and entrepreneurial managers—but in order to benefit from their talents we need to free them up, set them realistic goals and have sanctions for those who do not perform. We cannot have services carrying on, knowing that they will always be rescued.
I am feeling pretty cross at the moment because of what has happened at my London strategic health authority. Your Lordships may all think from reading the papers that London is a basket case. Well, the North East London Strategic Health Authority will break even this year—and I am very pleased to say that—but what will happen to the money that it has not overspent? It will be loaned around to the other basket cases in London that have been overspending.
The money that I was planning we should invest in the kinds of services referred to by the noble Lord, Lord Fowler—such as our desperately difficult and challenging sexual health services and the maternity services in east London, which are in dire straits—will be put on hold while we sort out the problems, again, in north-west London. Does that make good management? I suggest that it is not the managers that are at fault but the way in which they are supported within a national bureaucratic system.
The NHS working like this is doomed to failure. There are no incentives to perform therefore it is not surprising that we have spent 50 per cent of the money on increasing salaries—some are worthwhile; others I have more doubts about—yet we have had almost no increase in productivity. Many services have improved, but nothing like as much as they should have done. Turnaround teams will come in and help failing hospitals but they will not be able to tackle the political issues involved in intervening to ensure that services which fail can be closed, taken over or removed. Monitor has raised this issue time and time again and I ask the Minister when we will have a failure regime.
The second major problem is the weakness in commissioning and procuring services. We are now to have three layers. Primary care trusts have been largely a failure. We are going to reconfigure them to make them bigger, but will it make them better? I doubt it.
I recently had a visit from representatives of the New York Public Health Department, which commissions services from the New York public hospitals. It is very striking that this is done by senior clinicians and senior nurses—people who have been in the services for years—negotiating with clinicians directly and shaping the future. In other words, they are negotiating like with like. What do we have? Junior managers commissioning services in primary care trusts. We have tried very hard in my patch to change that and to engage clinical leaders in all the services.
But at the moment in Britain, clinical leadership of services is not what we expect. I was very proud to be one of the first clinical directors at Guy's after Sir Roy Griffiths's report in 1983. It seemed to me then that we were beginning to engage clinicians, but we have lost it again. Senior nurses and senior doctors began to run services and were proud of training to do it properly. We have lost that. Clinical leadership is absolutely crucial in running the health service right.
My time is up so I will make my last point. Your Lordships would expect me, as a psychiatrist, to mention the mental health services. It was Enoch Powell who said that it is the acute, voracious hospitals which suck up the money in the health service. The new White Paper about hospital care is uncosted because the money will be sucked in, yet again, to the acute hospitals. The people who really suffer from this are those with profound, acute mental health problems. They could be treated and would be eminently able to lead fulfilling lives if we gave them the support they needed. We are failing, yet again, to recognise that that arm of the NHS requires more investment.
My Lords, this is a topic of the utmost importance but perhaps I may remind noble Lords that it is a timed debate and that when the clock shows "8" we are actually in the ninth minute.
My Lords, I, too, thank the noble Baroness, Lady Cumberlege, for tabling the Motion today, which affords noble Lords—or myself at least—an excellent opportunity to place on record appreciation for the wonderful services provided in our National Health Service by those hundreds of thousands of dedicated professionals in every facet of healthcare throughout the UK. In every city and town in Britain, millions of patients each day are receiving health treatment, which is saving lives and healing bodies and minds, through modern methods of service delivery unequalled at any time during the history of the National Health Service. I contend that our Labour Government are truly fulfilling their commitment to the British people by modernising and energising the National Health Service and by making the vital investments to secure the major and minor improvements desired by everyone in our country.
In the few minutes at my disposal I can give eminent testimony to this proposition by citing the tremendous improvements that have taken place in recent years in my home town of Wolverhampton. The Royal Hospital Trust in Wolverhampton has achieved considerable success in access to services since 1997. For the past year, the trust has ensured that no patient waits longer than 13 weeks for a first out-patient consultation; no patient waits longer than six months for a day case or in-patient treatment; patients requiring treatment for cataracts wait no longer than three months; and similarly for patients requiring interventional cardiology or cardiac surgery. Equally importantly, since October 2005, no patient has waited more than 26 weeks for a CT or MRI investigation, and the waiting time for endoscopy investigations and treatment is now six weeks. The trust complies with the maximum two-week wait—from GP to first out-patient appointment—and the 31-day diagnosis-to-treatment period. In addition, over 90 per cent of access targets for cancer are achieved for the 62-day urgent referral for treatment. These achievements have been hard won by consultants, doctors, nurses and auxiliary staff, to whom I pay tribute, along with our Labour Government, whose generous investment, including our overspend in Wolverhampton, has brought about these major improvements.
This is by no means the end of the story. There is more good news. Thanks to the good judgment and foresight of my right honourable friend the former Secretary of State for Health, Alan Milburn, the Government approved the building of a 21st century state-of-the-art heart and lung centre during his period in office. It was one of the first developments of its type to be built in the UK, at an estimated cost of £57 million, and was built within budget and on programme. It was the biggest publicly funded scheme in the NHS at the time, funded wholly from the public purse. It is a magnificent facility, which has been serving the good folk of Wolverhampton, Dudley, Sandwell, Walsall, Worcester and south Staffordshire for the past two years, providing excellent treatment and care for a catchment area of more than a million people.
I wish I had time to convey the many other additional and refurbished facilities implemented, such as the Deansley Centre for cancer services, which is also sub-regional and provides excellent cancer treatment and care; and the Benyon Centre, which operates a first-class children's service, and day case and in-patient facilities for gynaecology and endoscopy. In addition, since 2003, New Cross Hospital has had a new radiology department, offering a highly efficient and professional service, which removes from Wolverhampton patients the necessity of travelling to Birmingham or Stoke-on-Trent for diagnostic treatment. The primary care trust is also developing valuable community healthcare services, particularly in mental health, through the excellent leadership of Professor Jolley and his team.
In conclusion, I say to the Minister: keep up the good work. I advise my right honourable friend the Prime Minister and my right honourable friend the Secretary of State for Health not to be overanxious about the additional expenditure. It is all beneficially contributing to rapidly improving patient care.
My Lords, the National Health Service is just that: national. It is supported by us all, valued by us all and it is our responsibility to see that the service it delivers is the best possible for the nation—for all of us.
Sadly, the current state of the NHS leads me to despair. This is not a political point; it is a statement of fact. The Government have poured money into the NHS, but with what result? There has been almost no increase in productivity, as the noble Baroness, Lady Murphy, so graphically described in a brilliant speech. There is, not to put too fine a point on it, chaos.
The current situation, in so far as we can even begin to unravel what has gone so woefully wrong, has been addressed by the oldest and least respected management response to a problem: "throw more money at it". This is always a short-term response, but every investment should always be both forensically tested before undertaken and constantly monitored to make sure that the effects are as forecast. This has not happened, is not happening and, unless the most uncomfortable lessons of the current situation are learnt, we shall end up with an even greater mess than at present.
In the 2004 spending review, the NHS is forecast to cost £76 billion in 2005–06. That, I repeat, is the spending review forecast, and takes no account of the deficits in the news this week. Those who say that even if the accumulated deficits amount to £l billion, or even £2 billion, this is not a gigantic problem as it amounts to only 0.12 per cent of GDP, should perhaps bear in mind that the reserve in the spending review amounts to £2.7 billion. Do the Government believe that no other department will overspend?
Economists are frequently accused of manipulation of statistics, but there is no manipulation in my comments today—that I promise. The reality which the latest news of the deficits in the NHS brings into focus is that government expenditure is out of control. More than that, it is dangerously out of control. This affects the NHS in particular, but it also affects every other aspect of our economy.
Government expenditure as a percentage of GDP has risen from 39 per cent in 1997–98 to a forecast of 41.9 per cent in this financial year—an increase in the proportion of the country's GDP of 7.4 per cent. The rise has been inexorable. If this rise had been matched by a corresponding increase in the efficiency and effectiveness of public services—particularly the NHS—there would be few who would criticise. However, this is patently not the case. The NHS is now in such a mess that every top brain that could be mustered should be mustered to try to help rescue it from a pathetic business situation where the staff are demoralised, the service is falling down in so many areas and, despite all the money thrown at it, deficits mount. Are Ministers listening to any of the messages being transmitted loud and clear from so many sections of the NHS?
We have already heard, in brilliant speeches, that the NHS has been subjected to reorganisation after reorganisation. The wonderful doctors, nurses, and all other employees are confused. This is not an over-the-top comment. I have heard so much of it, and, knowing what trauma has been experienced in business by reorganisation after reorganisation, I can utterly appreciate the frustrations and insecurity that have arisen. A demoralised, frustrated and insecure workforce can never sustain top quality service over the long term, which is what matters to us all.
Gaius Petronious, a Roman who had strong views, and has been proved right some 20 centuries later, famously vilified the concept of frequent reorganisation on the basis that it created an illusion of progress while producing chaos. My noble friend Lady Cumberlege gave us details of the merry-go-round of that process. When I was in business I had a quotation from Petronious on my desk, as did many of my colleagues in the companies in which I worked, and others. I recommend that Ministers—particularly those involved in the NHS—do likewise.
A grim analysis, but the prognosis is even grimmer. The current situation cannot be allowed to continue. I do not want to criticise the Government, but I want to suggest that their lack of basic management experience and their gullible acceptance of the so-called solutions proposed by armies of consultancy experts must be addressed. There are many who can help, but they are not on the Government's radar screen. The genie has been let out of the bottle, and policies regarding the involvement of people willing to contribute their experience and expertise should be subject to much greater independent scrutiny.
I was astonished to see proposals in the recent Natural Environment and Rural Communities Bill to the effect that non-executive directors appointed by government can have pensions. This would be totally out of order in the private sector. It is just another example of government throwing money at a problem, and this time turning a blind eye to the fact that the burden of public pensions commitment on every household in this country is £40,000, according to the news today.
Please consult with people of proven international success in this country, even if they do not happen to be card-carrying members of the new Labour Party—this is another, less effective, way of endorsing what my noble friend Lord Fowler was saying. It is in everybody's interests that this problem should be addressed and solved. This is a matter of higher priority than anything else, other than the security of the state.
Even before the news this week, I was shocked into the realisation that the situation of one significant sector of our population has deteriorated so much during the past few years. My shocked reaction was to the "Panorama" programme last Sunday evening on the long-term care of the elderly and infirm. I hope that the Minister saw the programme. If not, I suggest that he obtains a video recording and views it as soon as possible. The situation depicted in the programme was nothing short of scandalous. We are an ageing population, we are living longer and we can no longer rely on family to look after us at any age, even old age—or, indeed, middle age—due to the inexorable erosion by the Government of the importance of the family.
During a 12-year period I had first-hand experience of the parlous state of those who try to exist while suffering from long-term, hugely debilitating chronic illness. No one who has not gone through this has any conception of how devastating it can be. Our elderly and infirm are now on the scrap heap. There is no dignity and little compassion and there is intense worry about financing long-term care. Is that fair? Is that just? Is it what one of the leading countries in the world should be doing to those who have contributed all their lives to the state?
I guess that it does not matter much to a Government who have so little respect or concern for the family. It does not matter that houses have to be sold and old people are left unable to pass on anything—other than debts for care—to their children and grandchildren. The NHS is there for them—but at what price? Free to all at point of need? Do not even bother to answer. I do not think so. Surely we must reassess where the NHS is going—and do it now. As the right reverend Prelate the Bishop of Portsmouth said, there is a collective desire to get out of this mess.
My Lords, I thank the noble Baroness, Lady Cumberlege, for introducing the debate. I must declare an interest as I am a user of the National Health Service. I also have the privilege of being a member of many of the parliamentary health groups. Many of us from both Houses are kept up to date on health issues. Last night, I attended a dinner in another place. We were told how important it is to prevent deep vein thrombosis when patients go into hospital for operations. Each patient should have a risk assessment, and if they are at risk of blood clots and thrombosis they should be given blood thinners.
Prevention is better than risking death, which can be prevented. More awareness of that matter should be made public and all doctors should know the risk. Far more people die of thrombosis in hospital than MRSA, but all those avoidable deaths should be prevented. I find many people using the National Health Service have problems with finding who provides what. I have come to the conclusion that it would be helpful to users of the National Health Service if there was an information hotline to the PCTs that could be of benefit to patients, carers and staff. The correct information is vital. It is not getting to the patients.
The White Paper stresses health and social care working together in partnership. I have had experience of when that did not happen. We had to find which sling would be best for my husband, who for some time has had to use a hoist. The expert adviser on slings, who happened to be a health and safety officer from the hospital, advised that a sling made out of parachute silk, which could be sat on, would be the best. However, the occupational therapist from the social services who supplied the hoist would not agree to the parachute silk sling.
I grew frustrated at such non-co-operation between two professionals, so I went to the firm that made the sling to buy one direct. That was not as simple as I thought it might be. It had to be sanctioned by one of the professionals. I had to chase the health sling expert all over the north of England on his mobile telephone as he worked part time as an adviser to several health establishments. Getting something as simple as a sling, which I was paying for, became a major frustration because I was convinced under our circumstances that that sling was the most suitable. I was not going to give up. Many people might have done, but in the end the sling arrived and it has been useful.
In an ideal world of course people from the caring professions should work together in co-operation. However, it was evident from the "Panorama" programme on Sunday evening about nursing homes how difficult and expensive social care has become.
I am president of the Spinal Injuries Association. We in the UK have been among the leaders in spinal injury treatment. I hope that that will continue in the future of the NHS. It is absolutely proved that patients who have spinal cord injuries and go directly to spinal units, as long as their condition allows them to be moved, have fewer complications such as pressure sores, depression, and bowel and bladder complications than those kept in general hospitals. The Spinal Injuries Association fears that if PCTs run out of money patients may not be sent to spinal injury units. We would much prefer the money for that specialised treatment to be provided nationally.
Last week I asked a bright young man, who was a tetraplegic and had been treated at Stoke Mandeville hospital, what he would suggest if he could have one improvement. Without hesitation, he said, "Better fresh cooked food". That would get patients better more quickly and would help to prevent pressure sores and be good for morale. Good food for better health should be a priority for such severely ill patients.
I should like to bring to the Minister's notice the spinal unit at Oswestry. For those people who do not have suitable homes to go when they are ready for discharge, it has two halfway houses called Transhouse, one at Oswestry and one at Telford. They have all the facilities available for the patients to try out different equipment before the adaptations are carried out in their own homes. That avoids bed blocking and gives the patients time to get their houses sorted out. It would be of benefit if some other spinal units throughout the country had such facilities.
There are so many demands on the NHS, but one section where improvements could be made seems to be for people who develop osteoporosis. Given that one in two women and one in five men over 50 will suffer a fracture, how do the Government justify the exclusion of osteoporosis from the quality and outcomes framework of the general medical services contract? What are the Government's plans to increase the early detection and treatment of individuals with osteoporosis, and will osteoporosis be included in the next review of the quality and outcomes framework?
Further to the Government's announcement of additional funding over three years for DXA scanner machines, what measures are in place to ensure that the additional workforce and capacity are there in support? An estimated 3 million people in the UK suffer from osteoporosis. Every three minutes, someone in the UK has a fracture due to osteoporosis. Each year more there are more than 230,000 fractures in the UK. Osteoporosis costs the NHS and the Government more than £1.7 billion each year. The Government have a champion in the noble Baroness, Lady Royall. I hope that they will make use of her expertise as an adviser on the subject.
I end by asking how the White Paper will be funded. Will the funding come from existing work streams in both health and social care or will there be any new money? How will the charging policies in social care be reconciled with healthcare where the premise is free at the point of need?
My Lords, I must start by declaring an interest. I have chaired a health charity called DIPEx for three years, which provides patients with information to help them live with serious conditions and health issues. The NHS has embraced our work and has been a wonderful support. I will describe what DIPEx does more fully later. Health is not my field. My knowledge in this area comes from having been with Marks & Spencer for 34 years, when our involvement in the health and well-being of our staff was a core policy; and Tesco—mentioned earlier—learnt from us.
Today I am going to talk about informing the patient. I learnt at M&S that when people have choices to make they want to know what other people did in similar situations. When people of any background are given time to talk about their illness, and are given help to understand their options by knowing what others did, their ability to cope is improved, their propensity to have better outcomes is enhanced, and it helps the well-being of their carers, friends and family.
So on the basis of what I learnt at DIPEx and M&S, I want to congratulate the Minister and the NHS on their emphasis on providing patients with information, and to press upon the noble Lord the need for these services to include patient experiences. Secondly, I want to thank the department for the support it has already given to DIPEx and to remind the noble Lord that the young need special information and stories from their own generation. Finally, I suggest that the Government support a conference that will bring together all those who wish to help the NHS to get the right information to patients at the optimum time.
Perhaps I may take a minute to quote from a book called Information Therapy written by Donald Kemper and Molly Mettler. They are developing, on a large scale, the concept of information prescription in North America. This quote from their book should give an idea of how it could apply to us here. As they come from Boise, Idaho, the original language is a bit American, so I have anglicised it a little for this quote. On the first page they say:
"By offering every patient the right information 'prescription' as part of the process of care, the NHS can achieve measurable improvements in medical outcomes, patient safety, overall cost effectiveness of care and patient satisfaction".
The White Paper, Our health, our care, our say: a new direction for community services, shows that the Government understand all this and are beginning to use the term "information prescription" and that they intend to develop a system of delivery in the UK by 2008.
My first suggestion is that when developing information prescriptions for patients, of course people must have facts, and these facts must be properly researched. But people learn better from stories. So other patients' stories and experiences should also be available to patients and they must also be properly researched. If the Government were to include properly researched patients' stories in their information systems, this would be a powerful tool to help people make choices, give them support and help them manage their condition.
Perhaps I may now explain what DIPEx already does in the UK. DIPEx is the patient information system that includes the real patient experiences. It is the patients' voice. We knew that newly diagnosed patients wanted to know what happened to other people in similar circumstances to their own: what choices did other patients make, and how did they feel now about the outcome of those crucial choices? This is exactly what DIPEx provides for them. It already has 33 separate sites: eight for cancers, four for the heart diseases and others for depression, epilepsy and rheumatoid arthritis. We are adding more every month.
DIPEx has hundreds of voices of real patients talking about their real-life experiences and feelings. It is accessed heavily by patients and their friends. It is also used for training all levels of health professionals. It is unique in giving the real patients' perspectives from several angles. We ensure that with professional researchers, based mainly at Oxford University, covering patients' stories that include the good choices and experiences people had, the difficult periods and dilemmas for patients and their families, and, in some cases, the bad times and wrong paths people felt they had taken.
We are really grateful for the Government's help and support since our inception, and for their encouragement recently to develop a new service YouthHealthTalk.org, which covers teenage cancer, sexual health for young people, acne, asthma, diabetes and the like. The department is supporting the launch of this young people's website on 22nd of this month, where Philip Pullman, the award-winning author, will be talking about the power of storytelling and Jon Snow, our founding patron, will explain how this new project will develop its own style for youth. So my second request is, of course, that the Government look favourably on the further funding needs of DIPEx and YouthHealthTalk.org.
My final point could easily be made in the next debate on the value of the voluntary sector: that we are envied abroad. Wherever we talk of DIPEx with people concerned with patient information, be it in Europe, Australia, America or Russia, they say they have nothing as comprehensive as the voices we have collected at DIPEx. Our work is voluntarily organised by the trustees of our charity, and the stories are given voluntarily by good people who are ill and who know that they are helping others by telling us their stories.
People around the world are so interested in what we are doing here that they want to include DIPEx-type interviews in their own patient information services. So my final suggestion is that the Government lend support to a conference that is to be arranged here in London later in the year, where those leading the developments in patient information will consider the concept of information prescriptions, discuss the importance of including properly researched patient experiences in all systems and what needs to be done to adapt the new information structures we are building here to get the right information to the right patient who needs it in the right dose. I hope that the Minister might agree to speak at such a conference.
My Lords, it is a pleasure to follow the noble Lord. What he said about patient information is very important. I know that everyone in the House will be delighted that the right reverend Prelate the Bishop of Portsmouth, who is no longer in his place, is back and restored to good health. He said that he could not see why people would want choice if they had a very acute condition. If I had a very acute condition, I would want to know where was the best place to go, and I would want to be able to make that choice. Information on that is clearly very important.
I thank and congratulate my noble friend Lady Cumberlege not only on securing the debate but also on a devastating speech. Anyone listening to that speech must be asking themselves: why did Sir Nigel Crisp resign? Surely, it should have been the Secretary of State for Health. It is a damning indictment of the incompetence which has been shown by the Government. The fact that a senior civil servant has had to fall on his sword adds insult to injury. I am perhaps less charitable than my noble friend. I have to ask: what must it be like around the breakfast table in those households where the breadwinners are facing compulsory redundancy in the health service because of the financial mismanagement of this Government? They look at their newspapers—they are worried about their jobs—and what do they see? They see that the man who is apparently to blame is to be given a pension which most people could only dream of and a place in this House. What has happened to the concept of ministerial accountability? I suppose that the noble Lord, Lord Warner, will have some accountability when the newly ennobled Lord Crisp sits on these Benches and is able to ask him the questions, instead of providing the answers for the flip-flop policy which we have seen over a number of years. How can we expect people to have any confidence in our system if they see incompetence on this scale and no one carrying the can for them?
I was not impressed by the Secretary of State's response to this crisis, which was to go out the next day and make an announcement for a new £1 billion PFI project, for which people have been waiting years. Does she think that we are stupid; that we cannot see that this is just a piece of spin to try and draw attention away from the real crisis which is enveloping the health service?
I give the Government credit. They have been as good as their word in increasing spending. NHS spending has been growing at 6.5 per cent in real terms. Public spending has grown in the biggest ever single leap; by 5 per cent of GDP. So the Government have certainly spent the money, but the money does not seem to be having much of an impact on the NHS where every year since 1997 productivity has fallen.
I very much enjoyed the speech of the noble Baroness, Lady Murphy, who asked a key question. Why should efficient health authorities in London find their plans damaged because they have to bail out other people? The Secretary of State should see to it that those who have been doing a good job should not be penalised. The King's Fund has estimated that 73 per cent of the new money going into the health service simply disappears like water in the desert soil. Of course, some of it is being spent on pay rises. I am second to no one in my respect and enthusiasm for the people who work in the health service, but they deserve better leadership than this.
If we have this scale of crisis now, with spending running at 6.5 per cent in real terms, what will happen in 2008, when the Chancellor projects the increase in total public expenditure coming down to 1.8 per cent? I am pleased to say that I have the answer. It is in the form of a quote from the previous Secretary of State, Mr John Reid, who told the Health Service Journal:
"after 2008 there'll be less demand on the primary and secondary sectors, but more importantly we will have got rid of the 1.25 million people who were on waiting lists. That should ease the challenge after 2008".
Does he seriously believe that? If he does, he should not be anywhere near any government department or running anything. Anybody who has looked at the challenges facing the health service can see that fundamental reform is required.
I shall give one example. I used to be in charge of the health service in Scotland. I spent £4.4 billion in my last year in office. Today, the expenditure in Scotland is more than £9 billion. In 1997, my in-patient waiting time was 34 days. I acknowledge that that was far too long; we paid a political price for it. The Minister shrugs his shoulders. Today, the waiting time has gone up to 44 days. Out-patient waiting times then were 16 days less than they are today. The number of people waiting for six months has more than trebled. Spectacular spending has produced longer waiting times and waiting lists. Only today, we discover that a bit of a mistake, an error of judgment, was made on the consultant contract in Scotland. As with the Scottish Parliament, big numbers are always involved. The error amounts to £273 million of unanticipated expenditure.
This Government have tested to destruction the proposition that extra expenditure will result automatically in improved public services. So what is the remedy? The remedy lies in getting Whitehall out of interfering in the day-to-day activities of hospitals and GPs. It lies in breaking the state monopoly of the provision of patient services. I have a marvellous quotation which summarises what needs to be done. It states:
"We must develop an acceptance of more market-oriented incentives with a modern, reinvigorated ethos of public service. We should be more radical about the role of the state as regulator rather than provider, opening up healthcare for example to a mixed economy under the NHS umbrella, and adopting radical approaches to self-health. We should also stimulate new entrants to the schools market, and be willing to experiment with new forms of co-payment in the public sector".
More competition; ending the monopoly; bringing in charging: who said it? Was it David Cameron? No, it was Tony Blair, three years ago as Prime Minister. When will this Government put their rhetoric into practice? If they are prepared to do so, they will find common ground with people on these Benches and even some on the Liberal Democrat Benches. The truth is that they have been telling the people what they want to hear for far too long and the victims have been the sick and those in need of patient care, who are now suffering, along with the taxpayers, who are faced with liabilities and bills which are simply unsustainable.
So let us look for a radical reform of the NHS. Let us acknowledge that this model has failed, in the way that the old nationalised industries failed. They failed because they did not have to please their customers; they failed, as the noble Baroness, Lady Murphy, pointed out, because they knew the taxpayer would always bail them out in the end; and they failed, most importantly of all, because they were constantly being interfered with by people who had political objectives and who were sitting in Whitehall, far too removed from the front line.
I again congratulate my noble friend on the timing of this debate. Let us hope that the Government will learn from this lesson. Too many people have suffered. The Government set out—with the best intentions, I accept—on a policy which has produced a disastrous outcome.
My Lords, I, too, thank the noble Baroness, Lady Cumberlege, for raising this debate and congratulate her on her excellent speech. In the short time available, I shall link a statement made yesterday on Radio Four's Today by the Secretary of State, the right honourable Patricia Hewitt, where she referred to the need to balance financial accounting with the delivery of high-quality patient care, and paragraph 1.47 in the Government's White Paper which states:
"We need strategies for work force development that support radical shifts in service delivery and equip staff with the skills and confidence to deliver excellent services often in new settings. Staff will increasingly need to bridge hospital and community settings in their work".
There is no doubt that much is to be done to redress the financial overspend, but there is a need also to redress the balance between emphasis on financial management and targets and patient care. The workforce will be required to meet this balance. The goals of the National Health Service remain unchanged; that is, the delivery of care to all at the point of need free of charge. The proposals for expansion of foundation hospitals and the proposals in the White Paper present many exciting challenges for new models of care, both in hospitals and the community. Certainly, these call for intensive workforce development to ensure that the highest quality of patient care is delivered.
I was struck to hear a director of nursing and deputy chief executive of a foundation trust conclude his presentation last week on managing MRSA in his hospitals by saying that trying to engage board members' interest in anything to do with patient care was one of his most difficult tasks, because most of the members of the board were business people whose focus was on finance. He said that it was difficult to engage them in patient-care issues. Perhaps if patients were referred to as "customers", this might have more meaning to the members of that board. This point was again emphasised only two days ago by a group of 16 matrons and senior ward sisters who are on a clinical leadership course in a foundation trust in the Midlands and who came for a discussion with me in this House.
Nursing has been my professional life—I have to confess, for a longer time than the noble Baroness, Lady Murphy, having gone through seven reorganisations. I am delighted that the Burdett Trust for Nursing has launched a Leadership and the Business of Caring project. It has commissioned the Office for Public Management to carry out a study to form the basis for the development of executive nurses and the boards of which they are members. Performance management of patient care is as important as financial management if we agree that patients—or "customers"—are the business of the NHS. While all members of the healthcare team play an important role in the care pathways, the nurse is the member of the team who provides 24-hour care and plays an important advocacy role to patients and relatives.
Much progress has been made in healthcare delivery, in prevention, diagnostics, treatments, rehabilitation and long-term care in a fast-changing society, all of which is well informed. However, the media periodically expose some aspects of care that are far from acceptable; for example, in nutrition, personal hygiene, or cross-infection. These basic issues will remain important to the patient. Will the Minister give consideration to ensuring that a nominated person is given the responsibility, with authority for performance management of clinical care, to reflect care from the point of care delivery—that is, the bedside, health centre or clinic—through the organisation to the board? I am sure that the Minister will not be surprised if I suggest that this role might best be filled by the executive nurse on the board, who would not only fulfil the role of clinical performance manager, but also be the guardian of patient care, restoring care and compassion in whatever setting of healthcare delivery.
As well as being a nurse, I declare being a volunteer for more than 59 years. I am pleased that the White Paper acknowledges the part that the voluntary sector plays in the provision of health and social care. I am chairman of the National Association of Hospital and Community Friends—soon to become known as Attend. We, in partnership with NAVSM, represent 100,000 volunteers over 1,000 sites, and in 2005 contributed over 1 million hours' service, while friends groups contributed £45 million to support services in health and social care.
However, while the White Paper refers to barriers needing to be lowered—I will be speaking on that in today's debate—the Minister should take account of the current concerns over the late allocation of Section 64 and the OFV grants that are having a detrimental effect on patient care. Volunteers play an important part in supporting health and social care, and I trust that the Government will assist in promoting partnerships, as set out in the 2004 policy, "Compact".
My Lords, I thank the noble Baroness, Lady Cumberlege, for initiating this debate, as everybody else has today. I, too, am an optimist and see the glass as being half full, as my noble friend Lady Pitkeathley said.
My contribution is in two areas. First, it is extremely important, and not unreasonable, that those of us concerned with financial management in the NHS should be asked to keep the issue in perspective. While not belittling the challenge to those facing deficits or the frustrations of those who get it right—as the noble Baroness, Lady Murphy, so ably described earlier—I think that it is only fair that we should be reminded that the majority of NHS organisations are living within their budget and providing patients with better services. The Government's deficit projection currently represents 1 per cent of the NHS budget. I would be extremely pleased if an output from today's debate was a recognition of the value of NHS managers. Management in the NHS is often much maligned, particularly in the media. Maybe today we can see a turnaround of that perspective.
We do the NHS a disservice by playing down the enormous achievements of recent years. I always bang on about cancer, as I will again in a minute, but I remind the House that—in relation to coronary heart disease, for example—the mortality rate from circulatory disease has decreased by 31 per cent since the baseline of 1995-97. In 2003–04, 139,000 angiograms were carried out, compared with 81,000 in 1997. The number of cardiologists has increased by 58 per cent to 740 since 1999. These are just a few examples of key improvements. I am not alone in seeing the value of these changes. Most notably, the Healthcare Commission—a key independent organisation—said in its report, State of Healthcare, that "much should be celebrated", as,
"people are now able to gain access to many services more quickly and easily than in the past", and,
"long waits for hospital care have largely been eliminated".
My second point concerns the success in the field of breast cancer. We have seen some great results. Mortality rates have fallen by 20 per cent in the last decade due to screening and better treatments. How do we go forward from here? Yes, we need to improve early diagnosis and reduce radiotherapy waits, and that is starting to happen. The issue of access to leading-edge drugs for cancer patients, as exemplified by the debate about access to the drug Herceptin, is key. That is why it is tremendously important that charities such as Breakthrough Breast Cancer and Breast Cancer Care, with which I have been associated in the past, campaign vigorously on this issue, as it has implications not just for breast cancer patients, but for all cancer patients.
Herceptin is a breast cancer drug currently used and licensed for the treatment of advanced breast cancer in women with HER2-positive tumours. Research published in May 2005 suggests that it can be used to treat women with early-stage breast cancer with significant success. Progress in new drugs works by testing the drug with people with advanced disease and then bringing that experience forward into earlier disease. The potential benefits of Herceptin are clear and many clinicians are prepared to prescribe the drug off licence. Local cancer networks, such as the London Cancer New Drugs Group, have already issued interim guidance for Herceptin's use, prior to the National Institute for Health and Clinical Excellence's approval. The estimated cost of treatment with Herceptin for early-stage breast cancer is around £20,000, whereas the cost of treating late-stage breast cancer is around £100,000. Herceptin is suitable for only around 20 per cent of breast cancer patients who have a breast cancer classified as HER2 positive.
The costs of this drug and the surrounding PR have created a misconception that cancer drugs are expensive. This, if unchallenged, could have damaging effects for cancer patients in the future. Cancer will, I hope, one day become a long-term condition for many, with the prospect of disease management through a series of targeted medicines—some of which we can already see coming through the pipeline. Cancer drugs are not too expensive. The total NHS bill for all cancer drugs is about £600 million, as compared with about £800 million for statins, or £600 million for antihypertensives. These are only ball-park figures and crude comparisons. The NHS must afford new cancer treatments, otherwise what is the point of spending millions on cancer research? We are in a fast-moving world of innovation and we need to keep up. The NHS must strive to make new innovations available to patients more quickly. If BUPA can do it in days, why can the NHS not do it in less than 12 months? Has the manufacturers' delay in seeking a licence helped? I do not think so.
My right honourable friend the Secretary of State was right to state that Herceptin should not be denied to women on the ground of costs alone. I call on all PCTs to back the breast cancer specialists, the clinicians who prescribe their patients this potentially life-saving drug off licence. They do not do so lightly. Yes, a robust licensing system is essential. Nobody wants unsafe drugs to be prescribed without controls, particularly patients, as they are the ones taking the drugs. Yet, in this case, the early results are so promising and the patient need so time-critical that doctors are willing to take medical responsibility for prescribing Herceptin, so long as their patients understand the risks as well as the benefits.
There are many other new cancer drugs on the way. We need to find a way of speeding up the licensing and cost-benefit assessment process to keep pace with progress in cancer research. This decision-making process is vital to the mutuality in the health service that we have heard about; it is also vital if the Government's outstanding record on cancer is to be built on in the future.
My Lords, I, too, thank my noble friend for introducing the debate. I hope that she and other noble Lords will not mind if I restrict my remarks to some of the problems confronting dentistry at present. I declare an interest, in that I have been a dentist for more than 40 years, 25 of which were spent within the National Health Service. The Minister knows that I support the concept of change in NHS dentistry. I have praised the Government for their courage in tackling a dental service that has long needed revision, with an end to the treadmill of fee per item of service—which was recognised as long ago as the Tattershall report of 1964—and with help for the less well-off. But policy as it is today is in disarray.
Since the Prime Minister's promise in September 1999 that everyone would have access to an NHS dentist by September 2001, the build-up to the new contract implementation date,
"extremely concerned that in this vital area of services to the public, the DoH required Primary Care Trusts to take over the management of new contracting arrangements without ensuring that they had the necessary expertise and resources".
PCTs have serious funding problems. Their difficulties are reported daily in the press. Several PCTs are indicating that they have insufficient funds to maintain the existing level of dental services. It is even rumoured that the £1,000 that was promised to each NHS practice as an organisational development fund has been retained by some PCTs to pay their own staff. The promised fund for access, quality and choice, which was not distributed last year, is unlikely to be allocated this year. I should be grateful to hear whether the Minister has any new information on those two funds.
That reconfiguration and the huge uncertainty on funding for further growth have meant upheaval for PCTs and anxiety for a significant number of dental practices, which will lead to a reduction in the number of NHS dentists and a reduction in NHS dentistry. In some areas, the introduction of the new contract is actually discouraging any increase in NHS work. I am aware of practices that are planning to lay off dentists and staff because the contract value, based on earnings from October 2004 to September 2005, simply does not reflect the amount of NHS work that they are undertaking.
Although there are more NHS dentists, they are doing less NHS work, yet net expenditure has increased by 19 per cent since 2003–04. In 2006–07, expenditure is expected to be £1.66 billion, with a further £608 million recovered through patient charges. Last November, the Government reported that 1,400 new dentists had been recruited, yet a survey of 34 of the 109 local dental committees revealed that 90 per cent of dentists were experiencing problems with the calculation of their new contract. Fewer patients are able to find an NHS dentist. The proportion of the population registered has declined from 53 per cent in March 1997 to 48 per cent in March 2005.
The Government have insisted that patient charges should not represent a larger proportion of expenditure than they do at present, but the British Dental Association has calculated that income from dental charges is expected to increase in real terms by 28 per cent, despite the Government's contribution to NHS dentistry increasing by only 9 per cent.
Under the new contracts, dentists will no longer have the right to restrict their NHS practice to certain patients. The contract demands that care and treatment are provided to any patient who requires them until dentists have met their UDA requirement. A recent survey suggests that, already, 14 PCTs out of 303 are insisting that dentists do not treat adults and children differently. If PCTs insist that income from patient contributions is maintained—the minimum charge for treatment will be £42.40 from
Dentists have always been unhappy with the drill-and-fill treadmill, which encourages over-treatment and discourages discussion on preventive advice. The Government have stressed the importance of ending that arrangement with the new contract, but the new system, whereby a dentist must complete a fixed number of UDAs in a year, introduces a system of targets that is worse than the current system, where at least dentists have the flexibility to work as they wish. The new system should have been tested. The Government need to trust the profession, to make the profession feel part of the NHS family. I wonder why dentistry was specifically excluded from the White Paper Our health, our care, our say. That does not help morale.
I hope that the new implementation team that was recently announced to oversee the changes will take on the issues that I have raised and many more that time does not allow me to raise. If it can accept that changes should be made to ensure that prevention is the driver of the dentist/patient relationship and that dentists are allowed sufficient time with their patients, I am sure that NHS dentistry can prosper.
My Lords, like most people in this country, I am an enthusiastic supporter of the NHS. Like everyone else here, I am determined to get things right in both the short- and longer-term future.
My enthusiasm for the NHS stems from one of my very early childhood experiences—the sort of thing that stays with you. When my grandmother contracted bone cancer soon after the end of World War II, her six children had all either been in the services or were married to people in the services. No one had any money. They were trying to rebuild their lives after the war. The first drug to combat bone cancer was developed in the United States and the only way to get hold of it was through flights over to England every second day. Between them, the six children decided to do that and they were getting into more and more debt. One day, the NHS was introduced and she was kept alive for another two years through the NHS. That stays with you throughout your life, so I have a huge commitment to all of us working together to ensure that we get the future of the NHS right.
The Government's plans and the huge injection of money into the NHS have been very welcome, although they are mostly about organisation, process and, lately, the huge problem of financial management. Sometimes, we forget how quickly things are changing, partly because we now live in a knowledge-based society. That means that when a new drug is introduced, whether in Zurich, Australia or the United States, we want it. If it is for our loved ones, anyone we know or ourselves, we want it, we demand it. We want it in this country at our disposal and, wrongly, we think that we have a right to it, whatever the cost, with the NHS paying.
That is an enormous problem: how we pay and, therefore, how we ration drugs. It must be seriously addressed, perhaps through a national debate. We do not accept rationing by the ability to pay—quite rightly. We do not accept rationing by waiting time—quite rightly. We do not accept it by postcode allocation—quite rightly. We do not always accept the rationing that organisations, especially NICE, say is justified. We do not—at least, I do not—accept rationing because of age. I am sure that the noble Baroness, Lady Morgan, would not accept rationing by sex. None of us would. So how will we get drugs distributed to everyone who needs them?
Twelve pieces of guidance are due to be published in the next year for cancer alone on new drugs that hold enormous hope for treatment. There is very good news in people getting cancer treatment more quickly than they used to. The bottleneck in getting treatment has therefore shifted from secondary care to how the PCT makes choices about how to pay for those drugs. It is good that patients can get to the doctor more quickly, but so many new drugs are coming on to the market and entering our knowledge that we really must find a way of ensuring that these treatments are available. We know that cancer money is not always ring-fenced for cancer care alone. How can we deal with that?
The philosophy of the health service, which the Government are quite rightly determined to maintain, is equality of access to healthcare. There is a problem between equality of access in a national health service and devolution, because in many ways those are incompatible. As the noble Lord, Lord Forsyth of Drumlean, said, if one area is paying for the deficits in another area, you will get, not equality, but inequality because some areas will get more than others. Although that looks like equality in the longer term, it creates a big problem, both philosophically and in the implementation.
My Lords, I apologise for interrupting. I agree with much of what the noble Baroness has said, but surely the problem, as the noble Baroness, Lady Morgan of Drefelin, pointed out, is inequality of access. People with BUPA insurance get Herceptin; those who are in the wrong area do not.
My Lords, I agree completely, but this inequality is also embedded in the health service through socio-economic status, which I shall come to, which affects our health and our life expectancy to an absolutely unacceptable extent. If we do not tackle this inequality in access to healthcare, the difference in life expectancy in the population is more than five years. This is not about differences in the tendency to become ill; it is about differences in socio-economic status. Professor Sir Michael Marmot and others working with him at UCL have demonstrated that very clearly.
We must take a holistic approach that involves a national debate about how we are to distribute the treatments that people expect and deserve. I very much welcome the work already being done to bring together different aspects of care, such as health and social care, because people who have either acute illnesses or long-term illnesses do not fit into one silo. So far, because we have different methods of funding, we expect people to fit into those different silos, and it just does not work. It creates perpetual disputes. Cancer, for example, can involve treatment that does not apply if you suffer from Alzheimer's disease, when the care that you need comes under social care. Such differentiation is no longer acceptable.
The noble Baroness, Lady O'Cathain, quite rightly pointed to the huge problem of long-term care, which we must do something about. One of the problems with long-term care and the way in which we allocate resources is that many people still need residential and nursing-home care and will go on needing it. There is a huge problem with care staff not being available or qualified to provide that sort of care, which is in fact funded not by the health service but by social care. These need to be brought together. This is the Cinderella part of the service. These people need to be educated and trained to professional standards. We welcome those rigorous standards, but increased costs are making nursing homes and residential care homes go broke and simply close down while the need for that sort of care is increasing. So there is a crisis in funding and retaining care staff and long-term care homes. I am privileged to be associated with organisations, which are mostly voluntary but include academic bodies, that are looking into how that training and professionalism of care staff might be improved. That is part of the holistic approach that we need to take.
We must consider the huge mental health problems across Europe—about 80 million people will need mental health treatment at some point in a year. That is another huge priority which we need to take into account if we are to consider the long-term future of the NHS and make it work.
My Lords, one of the great advantages of being elected to this House by your peers is that you have the privilege of learning from professionals from time to time without being subject to elective surgery. I speak today as a total amateur in this subject. I admit that I have absolutely no idea how most parts of my body work, and I find that I have many common allies in the United Kingdom, but once you move into the international realm, the knowledge of what your body does, what biliary cirrhosis is or what each component ingredient mixes with, even with the knowledge of food, is important.
I was reminded of this when I saw a surgeon the other day and asked for advice. I said, "But surely surgeons are the most important people in hospitals. They are the dictators, the demigods, the gods". He said, "Yes, but we suffer from OCD"—I think he said obsessive compulsory disorder or something. I found that I knew nothing about all the acronyms and other abbreviations that are passed around by professionals. In many countries, the word "amateur" is a compliment. It means someone who knows and loves his subject. I have suddenly found that I am compulsorily interested in health but, for reasons different from those of all your Lordships, I see it as a really great opportunity.
I express particular thanks to my noble friend, who secured this debate, for adding so much through our colleagues today to my own personal knowledge. I appreciate it. I declare an interest in that my first involvement in the subject came when, by some accident or other, I was appointed to the board of the oldest health company in the world—a spa in Poretta, near Pisa and Bologna, which was known as Terme di Poretta. One of our skills was dealing with poison. We used to treat people who had been poisoned with lead by Lucretia Borgia. I then moved on in my commercial and banking world to find that the staff and serpent came from Egypt, where, of course, they treated with waters, and I learnt a lot about Prince Helwan and the others. We ended up financing and building a hospital in Egypt.
More recently, and with some regret, I have been a director of a construction company that has built 20 hospitals, with more than 2,000 beds. But we have lost so much money building hospitals that we have decided to stop building. I have found that other people have done the same. One great contractor, who shall be nameless, was reported to have lost £100 million on a recent PFI project. You do not knock the health service. I now regard it not as a service but as an absolutely essential public utility. It is a utility, and it becomes more and more essential as, to the regret of many life insurance companies, we live longer and longer.
I ask why 18 per cent of our utilities in this country are now owned by the Germans and much else by the French, and why we, who had some of the best run utilities in the world, have lost the way. I always felt that the gas man or the electricity man was one of the most knowledgeable people you could meet. Now, the bureaucracy that they face causes us concern. So when we talk about the efficiency of the health service today, I would not talk about the past, as the noble Lord, Lord Bilston, did; I would ask what other people do. I take as an example the health system in France, which I think is the best in the world, and which has 400,000 beds with 500,000 staff. Germany was not so bad, with 500,000 beds and 800,000 people. But in this country, with fewer than 200,000 beds, we are proud to have more than 1 million staff. Somehow, that is where the problem lies. But why should that be so important? We say with pride, "Look at the number of people within the health service". There are good people who are effectively thwarted by levels of bureaucracy and tiers that I find difficult to understand.
I found out the other day that we also have higher rates of pay for doctors than almost anywhere in Europe. Doctors want to come here because they will receive a higher net income than in their own countries. But they also want to come for some of the technological advances that we have in certain sectors, which included, for a while, new drugs. But the worries when people are doing animal testing and so on makes one realise that many drug companies may now cease or wish to withdraw.
I do not know what I would do if I was a Minister. I support the whole concept of the National Health Service, but it is extraordinarily difficult to determine how we can resolve this serious problem. In my days as a consultant I had a senior partner who was brilliant at selling himself. He would go to see a company and say, "I have been looking at your shares old chap. They have not been performing. The City does not understand you". There would be an immediate nod of acceptance. Then he would say, "I think that your problem is management". He would be addressing the managing director, who you could watch start to shudder and look nervous. Then my senior partner would add the word, "structure". The problem facing the National Health Service is not people or competence but entirely one of structure.
My Lords, I, too, thank the noble Baroness, Lady Cumberlege, for the opportunity to have this debate and for her introduction, which set the scene so well. I also welcome the right reverend Prelate the Bishop of Portsmouth back to your Lordships' House, and I noted what he said about choice. I took it from his speech that what mattered to him was quality of service and that he was not convinced about the extent to which choice was a factor in determining quality, for which I thank him.
The National Health Service Act 1946 sets out a vision of a,
"comprehensive health service designed to secure improvement in the physical and mental health of people", and,
"the prevention, diagnosis and treatment of illness".
That vision remains at the heart of NHS policy. It is as apt today as it was then, even though the context in which the NHS operates has changed dramatically—not least in terms of longevity. However, things have changed in the NHS. In 1948, a consultant was a medical god who attained the right to call himself "Mister". Now, a consultant is someone who appears from the DoH financial turnaround team to tell you what you are doing wrong in the management of your trust.
Several noble Lords have focused on the fact that increased expenditure has not been remarkable for increasing health promotion or prevention of illness; during the past eight years, it has tended to be in pursuit of political targets. It is against that background that we need to assess the long-awaited White Paper. I shall focus on a few areas of importance. One key factor is the stated aim of rebalancing the NHS in terms of preventative and community care. The Wanless reports give the economic background to the White Paper. They set out in great detail the economic impact on the NHS of failing to invest in social and community care. It is now accepted that failure to do so sets up high costs down the line for the NHS. That is the rhetoric of the White Paper. But the noble Baroness, Lady Murphy, had it absolutely right when she talked about mental health and the reality of how the White Paper downplays small-scale interventions for people who suffer from mental health problems.
The White Paper's emphasis on integration of the commissioning of health and social care is to be lauded. By 2008, all PCTs—the ones that are left—and local authorities—wherever they are—will establish joint health and social care teams to help people with long-term conditions. That will be an enormous challenge. As noble Lords have said, whatever the structures may be—we do not know what they will be—we will have to merge two entirely different systems; that is, an NHS system, which is based on capacity, and a social care system, which is based on eligibility. Nowhere in the structure has that key issue been addressed.
I want to concentrate on the cost of reform to the NHS, which is not so much reform as constant churn and disorganisation. One of the costs of reform, periodic as it is, is how it limits the ability of the NHS to deal with other agencies, such as local authorities and schools, all of which have a profound impact on public health. But the principal cost of reform is on the greatest asset of the NHS—its staff. The letter of
Another cost, which has not been mentioned today, is the haemorrhaging of expertise from the NHS. The average expectancy for a senior executive to be in post in the NHS or a PCT is reckoned to be two to three years, which represents a massive loss of investment, because the NHS invests well in staff training. That is exemplified in one paragraph towards the end of the White Paper. It made my heart sink. It said that over the next year, NHS staff will spend time mapping local statutory and independent services.
I have a way to save the NHS money. I know how people can do that in an afternoon. They find the dust-covered filing cabinet in someone's office. They take out the five mapping exercises that were done in the past. They look at them. Then they ask the voluntary sector to help them update the files and to fill in the gaps. There is a massive amount of expenditure in the NHS on unnecessary repetition because of a loss of corporate memory in the process of change. We should recognise that.
On NICE, I listened very closely to the noble Baroness, Lady Morgan of Drefelin. It has always been noted, particularly in the Wanless reports, that judgments about what is clinically and cost effective are complex and difficult. They are becoming more so as the pace of medical advance increases. But if, in the midst of all this reform, we do not maintain an independent, objective means of determining which drugs work, or not, whatever edifice is built around it, the NHS and medicine will suffer. Judgments need to be transparent and evidence-based. Findings need to be included in NSFs.
The recent case concerning Herceptin was interesting. I do not blame in any way patient groups who do what they believe to be the best for people for whom they care deeply. But politicians should accept what NICE says and that there will be differences in availability and in prescribing. That is a political difficulty. Ministers should stand behind NICE and give it their support, not use it as a shield.
Practice-based commissioning is a very interesting concept. GPs are perhaps one of the most stable parts of the NHS. They stay in an area, which they get to know very well.
People in the voluntary sector, where I work, are most interested in what the potential for practice-based commissioning is. First, it is practice-based commissioning, so not just GPs but all staff in practices need to be involved. Secondly, it has to be placed in a context where there is overall strategic planning for the health needs of an area. It is not clear from what is proposed whether patients who are expensive and complicated—such as those with HIV, as the noble Lord, Lord Fowler, revealed—will still have the same access to GPs, or whether they will become too hot to handle. It is also not clear what will happen to specialist commissioning for some of the conditions mentioned earlier, such as diabetes and particularly neurological conditions. What will happen to that?
Finally, what is going to happen about the overview of scrutiny of health provision in an area? There is an odd section in the White Paper that talks about calls for local action. On theses Benches we believe that it is right to go in the broad direction of the integration of health and social care, but there should be local control, which should be open, democratic and accountable. It should, as the noble Baroness, Lady Murphy, said, include clinicians—much more than it has done in the past—to ensure that choices are well-informed choices. I am pleased to see the emphasis on public health in the White Paper but I do not see how that can be fulfilled, especially, as was said at the time, when local government is about to be reorganised.
However we do it, we need a system in this country which brings out the best of local knowledge of acknowledgement which has behind it overarching skills, the research that we have talked about has been so necessary and above all else enables patients to know how and when they can influence the provision and work with the clinicians as the noble Baroness, Lady Murphy, said.
The White Paper holds out some prospects. Whether the resources are there to make it a reality is something on which the jury is going to be out for a considerable time.
My Lords, my noble friend Lady Cumberlege is to be congratulated on having tabled this Motion and on introducing it so superbly. I am sure we all agree that we have listened to some excellent speeches throughout this debate. I join my noble friend in thanking the noble Lord, Lord Warner, for changing his diary arrangements in order to be present to reply.
Some four years ago the Government did something bold and important and right, which was to start thinking seriously about how to put the patient at the centre of decision-making in the NHS; how to empower the patient; and how to give the patient a greater choice over what happens to him. In a state-run monopoly such as the NHS that somewhat revolutionary thought entailed certain consequences. It meant setting up payment mechanisms so as to enable money to follow the patient in response to the choices the patient made—the system known as "payment by results". But it also meant giving hospitals a greater ability to compete for the patient's favour and to be more responsive to local health needs. That, in turn, involved something pretty revolutionary, which was the idea of setting hospitals free of the shackles of central government control. Hence the foundation trust was born; and hence, to create greater capacity in the system, independent sector providers were brought in to take some of the load off the NHS—something that in May 1997 would have been inconceivable.
At the same time as all this, the Government did something else that was important and right, which was to address the problem of recruitment and retention in general practice; in the medical specialties; and in nursing and midwifery. Patient choice is not deliverable without doctors and nurses on the ground to deliver it. New contracts were negotiated with all three groups, the net result of which, in each case, was a very considerable increase in basic remuneration. Into the melting pot at the same time as all this was thrown another good idea: that at general practice level GPs should be able to commission services on behalf of their patients. Practice-based commissioning is not the same thing as the old fundholding, alas, but it strives to achieve what fundholding did, which was to give real choice to patients and to make the health service more responsive to what patients need.
If three years ago you had presented these reforms to a bank manager in the form of a business plan, there is one thing you would have been told, which is that every single one of these changes is potentially destabilising to the NHS. So when you budget for what it is all going to cost, you need to build in a healthy margin of safety to allow for the unexpected; and, as my noble friend Lord Fowler rightly said, you need to have high quality management to steer the reforms through what are very probably going to be some choppy waters. The Government would have done well to commission and heed such advice. They did not. And because they did not, it is not wrong to say that the NHS currently faces an almost unprecedented degree of uncertainty and instability, with inevitable knock-on effects for patients.
The large deficits we are now seeing are only part of the issue. The Minister is right to remind us, as he does, that as a proportion of the NHS budget the current deficit is not the highest it has ever been. But what is different today is that at trust level, there is now absolutely no give in the system. Many NHS trusts—possibly the majority—are having to cut back services; the reason for that is, quite simply, that the Department of Health got its sums wrong. The GP contract, the consultants contract and Agenda for Change were imposed on the NHS from the centre and are all costing a great deal more than the department budgeted. With the activity targets imposed on them, trusts have effectively had no room for manoeuvre. Worse still, as the noble Baroness, Lady Murphy, mentioned, these pay contracts contained almost no incentives to increase productivity, so that hospitals are being forced to save money in other ways that are extremely painful. But on top of that, the tariff system under payment by results is still immature. In a survey of PCTs and GP practices last month, 93 per cent of respondents said that the payment by results system was unfit for purpose and needs amending. Their chief criticism was that it encourages so-called gaming by providers to maximise income unfairly.
It is no tribute to the department that last week, only three weeks after publishing the national tariff for next year, it suddenly withdrew it and, in so doing, threw the business plans of the entire health service into a state of complete chaos. Simultaneously with that, leaders of PCTs were being told that their careers hung in the balance if they failed to produce improved financial forecasts within days.
We are witnessing departmental mismanagement on an epic scale Financial control of the NHS has effectively been lost. But there is a whole separate dimension to this. Last December the Government announced a major reconfiguration of NHS bodies. The number of strategic health authorities is to be cut from 28 to between nine and 11; and the number of PCTs cut by nearly two-thirds from 302 to a minimum of 115. This reconfiguration comes only three years after the last one; when, noble Lords will remember, the Government abolished the 100 health authorities, along with the nine regional offices of the NHS Executive. In other words, we are going back, after only three years, to almost exactly the same configuration of NHS bodies as we had before. The cost of this reorganisation in redundancy payments alone will be £320 million.
The reason given is that it will save the NHS £250 million a year. Whether it will or not remains to be seen, but it is not just the upheaval that this will bring. The Government are also proposing major changes to the structure of PCTs without first clearly defining what their role should be. Originally, Sir Nigel Crisp said that PCTs would become "commissioning-led" organisations with only a minimal role as providers. That was Government policy. The Secretary of State then contradicted him and said that it would be up to PCTs whether they continued to provide services. That inexcusable muddying of the waters prompted a broadside from the Health Select Committee in another place. The whole impression given is of policy-making on the hoof from the centre. Indeed, the public consultation exercise that took place last year might just as well not have happened.
The effect of all this on the workforce in PCTs has been deeply demoralising. It is a huge distraction from what really matters, which is delivering community services and public health services to patients and setting about the important task of implementing the recent White Paper. And for strategic health authorities, the task is formidable. How do you start to design new organisations unless you clearly understand what their function is going to be? How do you know if PCTs are going to be fit for purpose if that purpose is left open? And if, as a senior manager in a strategic health authority you know that your own job may not exist in a year's time, what does that say about your eventual accountability for the decisions that you take?
The Minister may be able to see his way out of all this, but from where I sit, we are looking at very serious central management failings that sit alongside, I am sorry to say, equally serious political misjudgments. The recent White Paper opens up some good and worthwhile policy ideas, but I say to the Minister something very simple. Let those ideas not be ruined by core planning. The White Paper is not anything like costed, a point made very powerfully by the noble Baroness, Lady Murphy, in her speech. The last thing we want is for services to move into the community, only then to be found to be unaffordable. Unless there is proper planning, moving services from the acute sector has the potential to destabilise NHS hospitals even further. That must not be allowed to happen. We must acknowledge that on top of all the other policy initiatives in the health service, the White Paper carries risks.
Over the next few weeks we need to see one thing: that Ministers have a plan to instil, contrary to all appearances, a sense of internal consistency and coherence into health policy. It is a tragedy for the NHS and for patients that that sense of coherence is now so noticeably absent.
My Lords, I am pleased that this debate provides me with the opportunity to welcome back the right reverend Prelate and I am very glad that the NHS was able to provide him with the services he needed at a crucial time. I have to say that I listened with mounting incredulity to the speech of the noble Baroness, Lady Cumberlege, about the wonderful NHS her government left us in 1997. I should remind her of some of the realities of those days. I know that collective memory can fail, as some have pointed out, but it is only eight years ago. The noble Baroness, Lady Barker, mentioned the Wanless report. Let me remind the House that Derek Wanless found that the cumulative underfunding of the NHS amounted to a staggering £267 billion—not million. That built up during the period when three of the former health Ministers who have been giving so much valuable advice to the Government today were each actually in charge of the health service. I just wanted to put that on the record. I like to provide the service of refreshing people's memory about some of these things.
That was the scale of the challenge we faced: an NHS budget of £34 billion; health funding in this country running at 6 per cent of GDP, pretty well the lowest in the EU countries at the time; waiting lists high and growing; one in 10 people on the list waiting for more than two years for their operations; A&E departments where elderly people commonly spent 12 hours on a trolley; and a topical reminder that in 1996–97 there was an NHS deficit of £460 million, which then represented 1.5 per cent of turnover. At six months into the current year, the deficit admittedly was a bit larger than that at £625 million, but it represented under 1 per cent of turnover. That is the historical record.
I was grateful to my noble friend Lady Pitkeathley for her timely reminder of some of the other management changes introduced by the Conservatives. It could be imagined from some of the speeches that there were no management changes during their period in office. I was also deeply grateful to the noble Lord, Lord Fowler, for recognising that his government's record might have had some impact on my own personal career development.
My Lords, I have to say that it was a life-changing experience when the noble Lord walked through the door.
I would suggest that it is the height of hypocrisy for noble Lords on the Benches opposite to fail to acknowledge their contribution to the problems of the NHS and the part that they have played. I also gently remind them that their party in the other place voted against a national insurance contribution increase that has funded some of the extra money going into the NHS.
I want briefly to remind noble Lords of what we have achieved. A number of speakers mentioned these, but I shall give a quick summation.
My Lords, I have to say to the noble Lord that I sat patiently through all the speeches from the Benches opposite; I would value noble Lords opposite doing the same while I respond.
My Lords, if the noble Lord were to wait patiently, he would hear the rest of the story. I hope that he will wait patiently while the rest of the story is unfolded for him.
We have put up spending from £34 billion a year in 1997 to £90 billion by 2008. There are 27,000 more doctors and 79,000 more nurses since 1997. I hope that no one on the Benches opposite is suggesting that patient care can be improved without having more doctors and nurses. Waiting lists are at their lowest point ever. Since last month, no patient has been waiting longer than six months for their operation, with the average wait now about eight weeks. These are some of the results that have been produced by the extra investment. Some 99 per cent of people with suspected cancer are seen by a specialist within two weeks of referral by their GP, and since 1999 we have recruited nearly 1,000 extra cancer consultants. Patients now have a choice of four hospitals or clinics for their elective surgery; early deaths from cancer are down by 14 per cent, and for coronary heart disease they are down by 31 per cent. These death rates, along with the suicide rate, continue to fall.
I suspect that if you were to ask most of those in the population who are affected by these conditions, they would say they think that they have had rather good value for money in the service improvements that have been made. We have 138 new or modernised hospitals after many years of under-investment, and there are many areas in which we have put in new equipment. We have, for example, 1,200 new pieces of modern equipment purchased over the past five years to help consultants in cancer save more lives. These are some very specific numbers to show where the money has gone. Patients no longer have to wait hours to be seen in A&E departments. In fact, 98 per cent of patients are now seen within four hours. Ambulance services are reaching 75 per cent of potentially life-threatening emergencies within eight minutes. Amid all this, as I have said, waiting lists continue to fall.
Other major killer diseases have been tackled more effectively, and as I have said, premature deaths from heart disease, stroke and related diseases have continued to fall. If this was not already impressive enough, we have also worked to narrow health inequalities. I do not remember health inequalities being featured that strongly by the party opposite when it was in office. Health inequalities have been closing at a rate of more than 2.5 per cent in less than half a generation. In essence, that means that services are reaching everyone in society, including those who need the most but in the past might have struggled to gain adequate and appropriate access. Patients and carers now have many more ways to receive and provide advice and help without needing to use traditional NHS services. Notable examples of offering care and advice at a time and in a way that patients need are NHS walk-in centres and the NHS Direct telephone service and website. These are just two examples of new ways to help people get more and quicker access to services and advice.
A number of noble Lords have talked about efficiency. Anyone would think that there have been no improvements in efficiency under this Government. The average hospital stay in England decreased from 7.4 to 7.1 days last year, delayed discharges have fallen by more than 60 per cent. in the past four years, management costs are down from 5 per cent to 4 per cent in the past seven years, and cancelled operations continue to decline. It is not just me and other Ministers saying this—these developments and improvements have been recognised by others. The Healthcare Commission, in its report, The State of Healthcare, commented that,
"much should be celebrated . . . people are now able to gain access to many services more quickly and easily than in the past . . . long waits for hospital care have largely been eliminated".
That is an independent body looking at the evidence available.
However, I recognise the realities that a number of noble Lords have brought to the debate. I pay tribute to the noble Baroness, Lady Murphy, for the way in which she has contributed to the NHS, and I congratulate her, in her capacity as chairman of a strategic health authority, on bringing her budget in on balance, with good-quality services provided across east London. We recognise that some areas of the NHS still need to improve. In 2004–05, the NHS ended the financial year in deficit for the first time since The NHS Plan was published. As I have said, that needs to be put in historical perspective.
In the current perspective, however, the majority of NHS organisations are delivering good services, with service improvements, and living within their budget, as the noble Baroness, Lady Murphy, explained. The concerns are in a minority of organisations, and we are taking action with the under-performing organisations to ensure that financial balance in the NHS is achieved by the end of 2006–07. We will say more about some of these issues at a later stage. The Department of Health has put in place a comprehensive programme to work towards rectifying financial mismanagement problems in that minority of trusts experiencing difficulties.
I recognise the upset and frustration caused to the NHS by the errors in the 2006–07 tariff, under-payment by results, which a number of noble Lords have mentioned. As the Minister overseeing this area, I apologise unreservedly for the technical errors identified. We are trying to put those right. We will work with the NHS to test revisions as quickly as possible, to get a seriously good assurance that the revised tariff will be correct and will enable people within the NHS to get on with their financial planning. I must acknowledge that we should have done better in that area.
What of the future? Several noble Lords have mentioned our new White Paper, Our Health, Our Care, Our Say produced after a major public consultation. One of my best experiences as a health Minister was spending a Saturday with 1,000 people in Birmingham listening to what they had to say about their health priorities and what they wanted to see from the public services that they were funding. It is absolutely clear that the messages encapsulated in that White Paper were the messages that people were giving to us. This White Paper was not dreamt up in Richmond House; it responds to and reflects the views that people have put to us. They want to see more services closer to home, more services not in hospital, local government and the health service joining up work together more effectively, and more effort put into health promotion and prevention. They accept that they should have more responsibility in terms of self-care, but they want the public services to provide more support to help them do it, and more support for the people caring for them. We have a journey to travel, but it is one set by the people of this country, not just by the Government.
Several noble Lords have mentioned some of the changes introduced by the Government. I am grateful to the noble Earl, Lord Howe, for his recognition of the improved change of direction that we have been trying to introduce in relation to plurality of providers, more choice in the system and practice-based commissioning. I share his views that practice-based commissioning will make a real difference to the more personalised and appropriate services that patients will get. There is clinical buy-in. I acknowledge that we might have worked harder on selling to, persuading and working with general practitioners in this area. In the past year or so, however, we have put a lot of effort into working with the profession, and we have got considerable buy-in. This is a direction of travel that they want to see.
We have had some criticism for the introduction of independent sector treatment centres, but not, I was pleased to see, from the Benches opposite. These centres have already cut waits for diagnostic treatments and elective surgery for 250,000 people with a relatively small proportion of the NHS budget. They have caused parts of the NHS to reflect on their own clinical practices and the way that they provide care services to patients. That is a good innovation. We are still strongly committed to moving down the path of hospitals becoming foundation trusts. They have to have their finances in good order to do that, for the kinds of reasons that several noble Lords have mentioned. We are not taking our foot of the accelerator in that area, however, and I have recently sent another 20 or so candidates for foundation trust status to Monitor, and we have a programme to continue that in the coming months. I cannot respond to all the points made by noble Lords, but I promise to go through Hansard carefully and to write to all noble Lords on all the detailed points and concerns that they expressed. I hope to be able to say yes to my noble friend Lord Stone about speaking at his conference.
I must respond to and correct one issue, which relates to the concerns expressed by the noble Baroness, Lady Cumberlege, about computerised applications for doctors under the new system of modernising medical careers. I freely acknowledge that there is an online application process. It is, however, marked by experienced doctors from the postgraduate deaneries. Computers have no say in that process. It is a fair, open and transparent process and provides a single gateway for all applicants and helps practitioners match applicants to vacancies. I have already written to The Times, which published today a letter rebutting the erroneous set of statements previously published.
In conclusion, our strategy of investment and reform was always going to have some bumpy periods because of the scale of our ambition to improve the health and social care system for all our fellow citizens. My noble friends have rightly paid tribute to the considerable advances that we have made in the NHS. Those advances are also a reflection of the huge investment of effort by NHS staff of all grades who have committed themselves to improving and turning round the NHS. We have to keep our nerve. I accept that things in some cases could have been done better, but that could be said of all governments. All governments could do things better with hindsight—hindsight is a wonderful thing—and I freely acknowledge that we have made some mistakes, but the direction of travel is right. We have hugely improved the services for people living in this country.
I finish by paying tribute to all that the NHS staff themselves have done—if I may put it this way—to rescue the NHS from the years of neglect under our predecessors. Working in partnership with doctors, nurses, allied health professionals, porters, cleaners, catering staff, managers and non-executives, we will come through this difficult patch. We will ensure that the NHS continues to improve and meets what I recognise are the understandable rising expectations of our fellow citizens. At the core of our debate are the needs of patients and carers, and it is on those that we all need to focus and make sure that we can make their lives better.
My Lords, I have a few minutes before the next debate; I know that this is a timed debate. I thank all noble Lords who have taken part. It has been a wise, wonderful and, on occasion, very humorous debate. I would like to reflect what my noble friend Lord Selsdon said—that seldom in this House do we sit through a debate without learning a lot, and today has been one of those occasions on which we have learnt a lot. We have learnt a lot from personal experience; often that is so compelling. We have heard about cancer, Parkinson's disease, DIPEx, spinal injuries, long-term care, sexual diseases, mental health, dentistry, carers, volunteers, St John, nursing and medicine.
At one point, I thought that we were going to have an auction of who had survived most reorganisations. The burden of the day—the major part of the debate—has been on the reorganisation and management, or mismanagement, of the health service. It is important that those who have been at the pinnacle of political decision-making—my noble friends Lord Fowler and Lord Forsyth—and have had real experience in the field should be listened to carefully.
My noble friend Lord Howe was more generous than I was, but he forensically exposed some of the flaws in the Government's plans. I am grateful for that. I thank the Minister for his reply, but I hope that he takes the message away with him which everyone has tried to reinforce—that there is a welcome to the increased expenditure in the NHS, but the question is whether it has been put to really good use. A little has, but an awful lot has been wasted. We have seen huge disruption with structural changes, and a lot of that has appeared simply at the whim of Ministers. Many of us in this House and many people in the country feel that the British people have simply been short-changed. I beg leave to withdraw the Motion for Papers.