NHS

– in the House of Lords at 11:36 am on 7th December 2006.

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Photo of Lord Colwyn Lord Colwyn Conservative 11:36 am, 7th December 2006

rose to call attention to the current situation in the National Health Service; and to move for Papers.

My Lords, my noble friend Lady Sharples provided an excellent curtain-raiser to our debate today. I look forward to hearing everyone's contribution.

Despite the benefit of increased funding and some real improvements, the NHS, which employs more than 1 million people and sees 48 million patients every year, is not well. All over the country, doctors are seriously worried by the continual and rapid introduction of new reforms, fragmentation of services, the lack of evaluation of new policy measures, overemphasis of the role of the independent sector and a lack of vision on the direction of travel. Continual change and reorganisation is having a detrimental effect on the morale of health service staff.

Essential healthcare professionals are losing their jobs and the NHS now forecasts a gross deficit at this stage of the year of almost £1.2 billion, already very close to the figure of £1.3 billion for the whole of last year. The organisational changes—from regional offices in 1997, via directorates, different numbers of strategic health authorities, and the change from health authorities to 303 primary care trusts, now merged to 130—are hard to understand. One has to ask whether this is good management.

It is the Government's mismanagement that has put the NHS in this financial mess. Despite all their assurances and promises, and despite the £155 million spent on consultants in 2005-06 and a further £22 million spent on employing "turnaround teams" to support NHS organisations in financial difficulty, they are failing to solve the NHS cash crisis. Last week, a survey of 29 accident and emergency departments under threat of closure revealed that 75 per cent of the NHS organisations which manage them were deep in the red in the last financial year. It is of great concern that these closures appear to be taking place for financial reasons rather than on clinical grounds. Just as the Government claim to be bringing care closer to people, they are planning to take local A&E and maternity departments further away. People do not feel safe with this. I hope that the Minister will be able to confirm that any savings made by closing some A&Es will be devoted to building others into specialised centres.

With more than 20,000 posts being lost, the total cost of NHS compulsory redundancies could rise to £70 million, and with cuts to front-line patient services being made up and down the country, it is becoming very difficult to trust the Labour Government with our NHS. Doctors report on cancelled clinics, empty operating theatres and patient referrals diverted to referral management centres, where patients are often redirected to another consultant's list. The British Medical Association is dismayed by the incoherence of current government policies and the damage they cause to the NHS and the delivery of patient care. Any NHS reform to deliver integrated care must be based on the values of co-operation, strategic planning and equity.

The recent restructuring of SHAs and PCTs has resulted in a commensurate reduction in the number of directors of public health. It is a concern that, as the timing coincides with NHS deficit recovery plans, PCTs will seek to reduce the number of specialist consultant public health posts. I hope that the Minister can reassure me that this important group of clinicians will be retained so that PCTs can deliver their vital public health functions.

It has taken a year for the Government to produce their proposals for NHS regulation. But those proposals will fail to ensure value for taxpayers' money and to safeguard the quality of care provided to patients. They do not even address important questions such as what support the majority of NHS organisations can expect if they are in danger of going bust. Under the proposals in the policy document on the future regulation of health and social care in England, the same organisations that have been responsible for presiding over the NHS's descent into financial chaos will have the same responsibilities in future. The same systems that have plunged the NHS into the red today will remain in place tomorrow.

The review of regulation represents a missed opportunity on a massive scale. It will not give the NHS independence. The NHS tariff will not be set independently, as clearly it should. The competition regime is not to be maintained by an independent regulator; it is a blueprint for continued financial failure in our NHS.

NHS commissioning that is led by clinicians working together across primary and secondary care will ensure that decisions on health services best meet the needs of patients. GPs should be given back the power to control their own budgets and negotiate contracts with health services, which the Labour Government stripped them of with their abolition of GP fund-holding in 1999. The proposal to introduce "practice-based commissioning" does not go far enough, since primary care trusts will still be the ultimate statutory budget holders. Government plans to change how NHS services are commissioned could provide a real opportunity to improve the range and quality of health services available to patients, but that will succeed only if there is a proper clinical engagement in both primary and secondary care and a meaningful dialogue with patients. The opportunity for every NHS trust to become an NHS foundation trust should be accelerated, and foundation trusts should be given greater freedoms to borrow to invest against their assets. Only this will deliver the flexibility that the NHS needs to finance its future capital investment.

There is no single cause of the NHS's current financial difficulties but a multitude of local and national factors. Constant reform and political interference have taken their toll, as have difficulties in managing deficits and strategic planning failures. The impact of NHS deficits in England has been wide-ranging for both patients and NHS staff. A BMA survey in 2005 revealed that one in three NHS trusts planned to reduce services because of deficits. Of the 171 NHS trusts that replied, one-third reported that their trust intended to reduce patient services. The Audit Commission's recent report on financial failure in the NHS found that organisations in financial difficulty routinely failed to engage senior clinicians in management decisions. This came as no surprise to doctors' leaders who have consistently called for greater clinical engagement in policy development and implementation. A criticism of engagement is that it comes too late in the process of developing policies or solutions to problems. All too often, Ministers will come up with a policy and then consult stakeholders about how to implement it. Doctors and other healthcare professionals should be engaged constantly in policy development to jointly analyse problems and co-produce solutions.

One major concern that health service staff have with the involvement of the private sector in the NHS and particularly independent sector treatment centres is the impact on local health economies. In some cases ISTCs have been imposed on local areas where their capacity was not needed or wanted. Health managers diverted resources for certain operations which had a negative impact on the existing local NHS services which were already performing these operations.

The concern is not that ISTCs exist, but that they exist in isolation from the NHS. There is a concern that the involvement of the independent sector has been implemented without provision for co-operation with existing NHS services, with preferential arrangements. This has the potential to threaten core NHS services. Medical centres operated by private health companies are treating as few as a quarter of the NHS patients whom they have been paid to handle. However, under contracts worth £1.7 billion given to companies to operate 18 centres since 2004, the money is paid whether targets are met or not, resulting in millions of pounds of taxpayers' money being wasted. I understand that the Department of Health has just signed new contracts worth £200 million with 14 private healthcare companies, which are to provide an additional 750,000 medical procedures.

Local financial difficulties have been compounded by national policies. The Government's commitment to commercial sector involvement in the NHS and the strain this puts on NHS finances is a key example. The preferential contracts awarded to commercial companies to carry out NHS work have meant that NHS hospitals lose out on essential funding. ISTCs are using NHS millions when spare capacity in the NHS goes unfunded and unused. PFI projects and the use of expensive management consultants are similarly draining vital funds from the NHS.

I am in favour of using the private sector, but the Government have clearly involved the independent sector without delivering value for money. Centres are not working to their optimum capacity and cost significantly more than the same service provided by the NHS. With the NHS in England recording a net deficit of £547 million in 2005-06, the suggestion that the NHS has had its best year ever must be disputed. This year has seen vital healthcare professionals losing their jobs, cuts in training budgets and doctors reporting cancelled clinics, ward closures and delayed operations. The Government have invested unprecedented funds in the NHS, and profound changes are taking place with virtually no debate in Parliament and without full and proper consultation with staff, their representative organisations, patients and the public.

With the current financial instability in the NHS, medical education and training in England are increasingly coming under threat, and this may affect patient care. Budget cuts to fund NHS deficits are draining vital resources from training and education for medical and dental students and threatening academic jobs. Continued cuts to training and education will threaten numbers of medical school places, worsen shortages of clinical academic staff and could result in the closure of some schools. Targets for the cuts include funding for junior doctors' study leave, which allows them to attend courses required for their training. These cuts are increasingly regarded as the soft option for trusts facing financial pressures, especially as they are no longer ring-fenced.

The NHS has a shortfall of doctors relative to demand. By 2008, the UK will need about 25,000 more doctors than it did in 1997. It is essential that the budgets, held by special health authorities, are protected. I should be grateful if the Minister could say what steps are being taken to ensure that clinical academic posts are not affected by NHS financial deficits and the non-ring-fencing of the multi-professional and education training levy.

I could not initiate a debate on the NHS without mentioning my own profession of dentistry. The reforms to NHS dentistry have not improved access for patients, and the Government have accepted that 2 million people who wanted to see an NHS dentist prior to 1 April this year are still unable to do so after the implementation of the new contract. About 90 per cent of dentists signed the new contract, but about 1,700 who previously had an NHS commitment did not. Many contracts were signed in dispute and the latest figures show that about 1,130 of these are still unresolved. I made some comments about the current dental situation in the debate on the Queen's Speech and it is not my intention to repeat the issues that I raised. I must, however, try to clarify the situation regarding my assertion that the drill and fill treadmill has been replaced with a new treadmill, one driven by targets which are not patient-centred.

When this came up in Questions in your Lordships' House on 21 November, the noble Lord, Lord Warner, was positive that this treadmill has been removed, but he must agree that the system does nothing to encourage dentists to take on new patients. Those patients, who may not have seen a dentist for several years, are much more likely to need more dental treatment than the patients who attend regularly and can benefit from advice on the maintenance of good oral health. Where is the incentive to take on new patients when the examination, scaling and perhaps one filling in one patient and the same examination, scaling and need for multiple fillings in another attract the same number of units of dental activity?

I am aware of dentists who have to see between 35 and 50 patients per day to meet their contractual targets. The meeting of the British Dental Association parliamentary panel last week was informed of one dentist who had to see up to 90 patients per day to meet her UDA target. Under the piloted personal dental service scheme, dentists had the freedom to commission services to meet local need. It was possible to ring-fence time for emergencies, meaning that patients with an emergency could have the full treatment on the first visit, rather than having to arrange another time some weeks ahead. Once an NHS dentist has met their target, they will not receive funding for any further treatment they perform that year. It is of great concern that some dentists may meet their target early and then be unable to provide patients with the NHS treatment that they need and which the dentist has capacity to deliver. I suggested that the Government regard the first year of the new contract as a test year. I believe that the figures for the first year will not be available until June and that the Government are committed to producing a report on the first 12 months based on the work of the implementation review group. This will enable a thorough review of the effects of the new contract. That opportunity must be grasped.

Any changes that improve patient care should be supported, but the Government should do more to recognise the progress made by their extra money and the hard work of NHS staff, and should make sure that change and reform involve support from the staff who have to deliver it. The NHS has repeatedly demonstrated its ability to foster innovation and is a proven mechanism that can deliver, and has delivered, reform. Reform must be based on the values of co-operation, strategic planning and equity and should deliver integrated care and an environment in which teaching, training and research can flourish. I beg to move for Papers.

Photo of Baroness Howells of St Davids Baroness Howells of St Davids Labour 11:52 am, 7th December 2006

My Lords, I register my appreciation to the noble Lord, Lord Colwyn, for initiating this debate when so many are concerned not with the treatment that the service is offering, which is very good indeed, but with the direction in which the NHS appears to be moving. I feel very fortunate to speak so early in the debate, leaving me plenty of time to listen to other noble Lords and, as usual, to learn from them.

I will do some gathering up and express some concerns from the community from which I come. The population's expectations of all public services are changing. They are more knowledgeable, and they expect to be treated as partners and equals and to have choices and options available to them. There is a strong perception, often backed by data, that services are not distributed equally and that inequalities continue to be a major challenge in the NHS; for the Government, for those who deliver the service and for the recipients. It is believed that to deliver on any of the realities, the contribution of the whole workforce and their ideas must be acknowledged, recognised and valued throughout the service.

The Government have defined healthy communities as being composed of individuals in good mental, physical and spiritual health who are able to contribute to wealth and harmony in their local communities. The Government's aspirations for enabling healthy communities have their conceptual origins in the benefits gained from the synergy between economic regeneration, higher education, and healthcare. That means that workforce development and equality programming in the UK is vital. I trust that we agree that enabling healthy communities through service innovation is a must for professionals providing public services in the 21st century.

There is a need to integrate creativity, communication and cultural understanding as unshakeable pillars, where all human capital, knowledge, skills and expertise are paramount in meeting the demands and expectations of us all. Knowledge-sharing is a force for building capacity towards the establishment of new and innovative relationships, built strictly on collaboration, trust and consideration among all stakeholders with a common purpose.

Yet, at this time, there is a major concern among professionals about the local improvement finance targets, known locally as LIFT. GPs complain about playing an unconscious role in the NHS and appear to be in conflict with government initiatives for data collection. They see their role as providing evidence-based medicine known in my local area as "medicine by numbers"—planned and priced medication with little regard to the health needs of the community.

Questions are being asked as to whether treatment centres, where the Government are heavily investing with the private sector, are good value for money and sustainable. These centres will not provide training for young professionals and their main purpose seems to be to cream off the least skilled jobs and do them quickly.

There are also concerns about the Government's commitment to positive discrimination, which is illegal in this country, by employing European Community nationals before all else, despite language and other barriers. Experience has taught us that the most successful implementation programmes ultimately aim to ensure recognition and remedies of both specific and common issues among individuals and groups if they are to participate in the improvement of services for the benefit of the whole community.

I am sure that the Government's intention, if they wish to achieve their objectives and outcomes for all their stakeholders, will be to continue to seek a structured means of communication, to influence actions and attitudes, to challenge views and to create new understanding, related to leadership, teamwork and service improvements in a more positive way than at present. Diversity of needs will then be a positive force for healthy communities at all levels. Patients, practitioners and all those engaged in delivering the service in whatever form will then continue to hold up our National Health Service as a beacon to all.

I should be grateful if my noble friend could answer some of the few concerns that I have raised.

Photo of Lord Rodgers of Quarry Bank Lord Rodgers of Quarry Bank Liberal Democrat 11:58 am, 7th December 2006

My Lords, I welcome the initiative of the noble Lord, Lord Colwyn, in raising today's debate. Shortly before the last general election, I recall another debate in the House to which I listened but in which I did not participate. Almost all noble Lords who spoke had been professionally involved in the health service and were well disposed to the NHS, saying that so many things were getting better. After the bleak Thatcher era and Gordon Brown's four lean years of public expenditure, there was now a perceptible improvement.

On the occasion of today's debate, the mood may be a little different. Last year, I did not quarrel with the apparent consensus. My knowledge and experience arose entirely from me and my family, and we were glad that the NHS was recovering. However, I thought that the debate was rather too full of self-congratulation and provided too little recognition of the gap between the much-improved NHS and the so-called world class to which the Government had chosen to aspire. The glass of success was half full, but it was still half empty.

As an example, I had applied at that time for my NHS hearing aids. In the House, Ministers proudly told us of the new digital appliances—the result of a successful deal between the public and private sectors. But I then discovered that fitting my hearing aids would take a full year, and elsewhere the delay was often very much longer. For those who had hearing problems, the glass was certainly still half empty.

I want to deal mainly with another current issue—the future of stroke care—and, again, I shall draw from personal experience. Today, I am not pursuing the subject of the highly controversial accident and emergency proposals spelt out by the Prime Minister this week, although I am not yet persuaded of their virtues. On 23 May, in a short debate, I had the opportunity to raise the National Audit Office report of November 2005, Reducing Brain Damage: Faster Access to Better Stroke Care. I explained that five years ago, I had been taken to the Royal Free Hospital, London, and then to the National Hospital for Neurology and Neurosurgery in Queen Square. A stroke had been diagnosed.

The National Audit Office report, the House of Commons Public Accounts Committee report which then followed, and the Government's recent response—the 52nd report, Cm 6924—have this in common: they agree that stroke is the single biggest cause of death after heart disease and cancer and that three times as many women die of a stroke as die of breast cancer. Nor does the department dissent from the PAC's conclusion that stroke costs the economy £7 billion a year, including £2.8 billion in direct care costs to the NHS.

I shall not set out further the large measure of agreement between the three reports on matters of fact. I concede that there have been significant improvements in the past five or six years and that stroke is now accepted as a medical sub-specialty, but I am unhappy about the tone of the 52nd report, which is bland, the lack of urgency on the part of the Department of Health and the apparent absence of additional resources sufficient to implement good intentions. In particular, I am greatly concerned about the arrangements necessary for scanning stroke victims.

The summary of the National Audit Office report said:

"There are barriers that prevent stroke patients from receiving rapid and responsive emergency care".

It continued:

"Large numbers of acute stroke patients don't get a scan within the critical time period".

Among the conclusions and recommendations in its report, the PAC said:

"All suspected stroke patients should be scanned as soon as possible after arrival at the acute hospital, ideally within three hours, and none should wait more than 24 hours".

The Department of Health agrees with the recommendations, and that is fine, but there is too little evidence in the report that serious progress is being made.

In my speech on 23 May, I drew attention to my interest in the Royal Free Hospital—one of my local hospitals. So, a couple of months later, I asked the Royal Free whether patients were scanned within three hours and whether they could be scanned 24 hours a day, seven days a week. In his reply on 22 August, the chief executive of the trust said that the hospital had the facility to scan patients 24 hours a day, seven days a week, and its aim was to scan within 24 hours of admission. But the hospital could not routinely scan patients within three hours and, in the last audit period, 10 out of 33 acute stroke patients were not scanned within 24 hours.

I am not making a target of the hospital. On the contrary, the chief executive gave a straightforward answer to my questions. But my guess is that the Royal Free is typical, plus or minus.

I am not asking the Minister to give an authoritative view this afternoon—that would be unreasonable—but I will table a Written Question to him to give me a complete picture, hospital by acute hospital, in answer to my two simple questions.

On access to stroke care, I am ready to concede that the glass is now half full, but I hope that in turn the Minister will concede that it is still half empty.

Photo of The Bishop of Worcester The Bishop of Worcester Bishop 12:05 pm, 7th December 2006

My Lords, I am grateful to the noble Lord, Lord Colwyn, for initiating this debate. It is clear from the three speeches already made that it will be a very wide-ranging and searching one.

I have come to take part in it because I hope to have some answers to some puzzles. I am genuinely puzzled and I look forward to hearing some resolution to them from the Minister and others.

It is clear that an enormous amount of additional resource has been put into the National Health Service. To deny it would be churlish and would fly in the face of the facts. The results are, in part, there to see, and one has to be grateful for that. My puzzle is that, on the other side, there seems to be a financial regime so draconian that people are asked to cure deficits within quite unreasonable times with disastrous results on any sensible scale of planning that they might have had.

Here is another puzzle. We have a wonderful, new-looking hospital in Worcester that we are told was put up without any impact on the public sector borrowing requirement. But we notice that in the deficit that has to be dealt with, a large part is owed to the company that built the hospital. Therefore, for all intents and purposes it looks exactly like a debt. We used to buy things on hire purchase more than we do now, and we always thought that that was a debt. I am a bit puzzled that something that feels like a debt, looks like a debt, and walks like a debt is not a debt.

We are told that there is greater devolution of authority to local trusts. Indeed, the Minister who will be responding has told me on more than one occasion of the importance of this policy of local decision-making. But experience on the other side is different. When I go to the local trust, it says that it is required by the Government to do certain things that it wishes to question. As to the localness of decision-making, the trusts appear to be free to make decisions that do not have the support of any of the democratically elected authorities in the area. Those authorities have great difficulty in even raising questions. That is a puzzle.

I shall make some points about targets. Targets are another puzzle. I understand what the Minister said in response to the Question asked earlier by the noble Baroness, Lady Sharples. He said that targets have an effect on priorities and bring about the raising of certain standards. But where are the targets for quality, gentleness, attentiveness, waiting or listening? Where are the targets that relate to the heart of the service?

Noble Lords will understand that I do not wish to say very much today about the particular chaplaincy crisis facing Worcestershire because this is the very day on which the board of the trust is meeting, and it may yet be possible for there to be some acceptable compromise. I very much hope that there will be, and I do not wish to say anything that might make that more difficult. That crisis is an instance of the absence of any will to enforce targets for the heart of the service. I want the Government to give that some attention.

The priest responsible for National Health Service matters in a diocese in which I previously worked was taken around a hospital by the chaplain. They entered a ward that was clearly in crisis—such things happen. People were rushing about in great distress; it appeared that matters were out of control. My friend turned to the chaplain and said, "What on Earth could you possibly do in a situation like this?". The chaplain replied, "Just walk slowly".

There needs to be a target for walking slowly. In most situations, that will be the only way to allow the reality of a person's illness, the reality of what staff are up against, to become clear. Chaplains, and their support across the faith communities, are part of that heart, as is nurse training, which we have heard is in some danger.

We have all been ill and we know that it is quite difficult to speak clearly about what is wrong with you unless somebody is spending time on it. I am not against targets, but I would like to see a target for spending "long enough" with a patient, not just ones that say how many patients you have to see.

The National Health Service is something of which we are not only proud, but for which we are hugely grateful. I am concerned about its heart, and some of my earlier puzzles are to do with that heart being in some danger. A National Health Service where nobody is asked to walk slowly is not one that will ultimately do us any good.

Photo of Lord Layard Lord Layard Labour 12:12 pm, 7th December 2006

My Lords, I shall talk about the problems of those with depression and anxiety disorders. First, I praise the huge improvements in the NHS under the present Government. It was an extraordinary and momentous decision to raise our spending to the European level. No other Government would have done it, and the benefit to patients has been enormous.

That is true of mentally ill people in the secondary sector as well as the physically ill. Compared to 1997, the secondary mental health services employ 50 per cent more psychiatrists and 75 per cent more clinical psychologists. Of course, the premises have often been transformed beyond recognition. However, the secondary mental health service provides for only about 1 per cent of the population—chiefly those who suffer from the serious conditions of schizophrenia and bipolar disorder. Another 16 per cent of the population suffer from clinical depression and chronic anxiety disorders, which can cripple their lives—one need only think of the hundreds of thousands who cannot even leave their homes.

That 16 per cent have always had a raw deal from Governments of all persuasions. For most of them, all that has been available has been either medication or, possibly, a little counselling. This provision is completely contradictory to the NICE guidelines—an extraordinary situation of which people may not be aware. The NICE guidelines recommend that, except where the condition is very mild, all those with these conditions should be offered modern, evidence-based psychological therapies. That guideline is based on hundreds of random assignment control trials which show that after less than 16 sessions of cognitive behavioural therapy, for example, half of all who suffer from these conditions will be cured. In addition, surveys show that patients want psychological therapy more than anything else. It is not expensive: the average cost is about £750. Is it not dreadful to think that millions of people in misery could be relieved by so little expenditure? It is even more shocking when we realise that the net cost of doing so is nothing because 1 million of those people are on incapacity benefit and being on that a month rather than working and paying tax costs £750, which is the same as the cost of a course of therapy. Huge savings could be achieved through more widespread provision of psychological therapy according to the NICE guidelines. I am not saying that we should treat people simply to save money—far from it—but if we can relieve misery and at the same time save money, it is a powerful argument for quick government action. On any reasonable calculation, it would cost the Government nothing net to implement the NICE guidelines in this area.

Implementing the guidelines on depression and anxiety disorders must be a top priority for the Government's forthcoming Comprehensive Spending Review. The aim must be to create an evidence-based psychological therapy service within every PCT to which GPs and jobcentres can refer their clients. That is what GPs want. They complain all the time about the absence of such a service, and the proposals put forward in The Depression Report, published by the London School of Economics, were backed by the Royal College of General Practitioners and the GP representatives of the BMA. The main danger is a dumbed-down response providing therapy on the cheap by inadequately trained people offering too few sessions aimed at improvement rather than cure. That would be false economy and is not based on the evidence. People who have these conditions should be treated as we would like to be treated if we had them. That should be the fundamental principle in the treatment of mental illness. For 50 years or so, it has been the fundamental principle in the treatment of physical illness, and it should apply to mental illness just as it applies to cancer. We must get rid of the remnants of the do-it-cheaply, poor-law thinking that we abandoned for physical illness 50 years ago.

We need an adequately trained workforce. One estimate is that we need approximately 8,000 more therapists than are now in the service. It is obvious that this problem cannot be dealt with overnight, and nobody is saying that it should be dealt with in the middle of this financial crisis. It should be dealt with by a phased seven-year plan. We have to have a clear concept of where we want to get to at the end, so it is necessary to start at the end, not the beginning. First, we have to decide what is an acceptable service; secondly, there needs to be a commitment to getting there by, I suggest, 2013; and, thirdly, there needs to be a national training plan for making that possible. All that needs to be spelled out in the settlement before the Comprehensive Spending Review.

This is a long-standing problem that has been ignored by Governments of all persuasions and, in fairness, I should add that the NICE guidelines in this area are only three or four years old. However, they are breached to a degree quite unknown with any other form of illness. To get a change of approach, we have to have a different perspective on mental illness. We need to recognise that mental illness is one of the main forms of deprivation in our society. Research shows that it causes more misery than poverty or physical illness. If we can recognise that mental illness is a major form of deprivation, I am sure that it will become a central policy issue in the years to come. Now is the time not only to plan for action but to begin it.

Mental illness has been with us since the Stone Age. What is new is that we now have the techniques for tackling it. It would be hard to forgive a Government if they did not rapidly make those techniques available to people who so desperately need them, especially when it would cost nothing.

Photo of Lord McColl of Dulwich Lord McColl of Dulwich Shadow Minister, Health 12:20 pm, 7th December 2006

My Lords, I, too, welcome the initiative of my noble friend Lord Colwyn in securing this debate. I should like to draw attention to the trafficking in human beings, which has such a serious effect on the health of its victims. The United Nations has defined trafficking in human beings as,

"the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat of use of force or other forms of coercion, of abduction, of fraud, of deception ... for the purpose of exploitation. Exploitation shall include .... prostitution ... forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs".

People trafficking is a global issue that affects virtually every country worldwide. An article in the Herald Tribune this week reports that the Council of Europe estimates that people-trafficking revenues have reached a staggering $42 billion. Nearer home, it is rather worryingly reported that an average of 100 unaccompanied minors come through UK immigration at Lunar House in Croydon each week. Of those, some 80 disappear. The strong belief is that most are taken by traffickers.

It is common practice for traffickers to make trafficked people memorise a phone number before they leave their country of origin, even though they do not know why. These people are often abandoned at the departing airports with their only option being to carry on with their journey. On reaching the UK, they expect—this is the deception—a helpful person to meet them and to provide them with the job that they were promised. When they arrive alone, the Immigration Service has to refer them to the police or social services and they are temporarily housed until, usually, they are flown back to their port of embarkation, where the traffickers are often waiting to retraffick them. This can happen 20 times in their lives. Often, before these people are sent back, they call the memorised phone number and are picked up by the traffickers in the UK. The police and social services have no idea of their whereabouts.

The effect on women of being trafficked is absolutely devastating. A report by, among others, the London School of Hygiene and Tropical Medicine, concluded:

"Trafficking often has a profound impact on the health and well-being of women. The forms of abuse and risks that women experience include physical, sexual and psychological abuse, the forced or coerced use of drugs and alcohol, social restrictions and manipulation, economic exploitation and debt bondage, legal insecurity, abusive working and living conditions, and a range of risks associated with being a migrant and/or marginalised".

In that study on violence and injury during trafficking, 95 per cent of respondents reported physical or sexual violence, 90 per cent reported being sexually assaulted, 75 per cent reported being physically hurt, 36 per cent reported receiving threats to their family, and 77 per cent reported having no freedom of movement. Those who had a degree of freedom generally described being accompanied by minders to prevent their escape. To retain control over each woman, traffickers, madams or pimps create an unpredictable and unsafe environment to keep them continually on edge. Most of the women were also denied access to healthcare during their experience. Immediately following their release or escape, most of them are burdened with numerous and concurrent physical and mental health problems.

What is the extent of human trafficking? At least 12 million people are victims of forced labour worldwide. Of those, 2.4 million are in that situation as a result of human trafficking. Eight hundred thousand women, men and children are trafficked across international borders each year. That is one person trafficked every minute. Approximately 80 per cent of those trafficked are women and girls. Up to 50 per cent of them are minors. An estimated 1.2 million are children. The majority of these victims come from the poorest countries and the poorest strata of the national population. Trafficking is the fastest-growing means by which people are caught in the trap of slavery.

We have no reason to be complacent in this country, bearing in mind that, quite apart from trafficking, 10 per cent of children are sexually abused. In 1998, the Home Office estimated that several hundred people being trafficked per year were forced into prostitution. In 2003, the figure rose to 2,800 and, last year, it was 4,000. What is the Department of Health doing about these health problems?

Photo of Lord Addington Lord Addington Spokesperson in the Lords (Disability), Work & Pensions, Deputy Chief Whip, Spokesperson in the Lords (Sport), Shadow Minister 12:27 pm, 7th December 2006

My Lords, I thank the noble Lord, Lord Colwyn, who is my friend, for bringing this debate before us today. I want the House to consider another aspect of healthcare where the NHS is rather underperforming: sports medicine, or, to use the correct term, sports and exercise medicine. From doing a little research, I discovered that there are currently only three consultants working in the NHS in that field. It is reckoned that we need a number in the mid-30s to provide basic coverage. According to some doctors in the field to whom I have spoken, at the current rate of training, we will get about a dozen by 2012.

Those statistics mean nothing unless I explain why the issue is important. Sports and exercise medicine is probably what will enable us to maintain a drive for greater physical activity among our population. The Minister for Public Health and the Minister for Sport are so often seen together at events because we recognise that greater physical activity has huge health benefits across the board. Many conditions, including most forms of cancer, are much less likely if you are reasonably fit. As for how you measure that, I have indulged in attacking the body mass index in the past, so I will not go into that again, but I know that someone who is fitter is at much less health risk.

How do we keep someone healthy? We can tell them to go jogging 2.3 miles three times a week, to eat less, to live a virtuous and moral life and not to watch TV too often, but we will fail. We already have. If we get people interested in a competitive form of physical activity—sport—they have an incentive to keep themselves fit. They will not be bored by the process. If noble Lords want proof of this, they need only look at the exercise industry. The way in which most gyms make money is that we all join in January, turn up three times, and forget that they are there by February. The industry itself is pretty open about this, to be perfectly honest. We need a way of keeping people interested, but once we have got them interested—this applies much further down the socio-economic chain and probably in this Chamber, too—we must ensure that they can afford to be fit. By that I mean that people must know how to be fit and how to maintain fitness without fear of injury.

Many of my rugby-playing days were spent at a small club in Norwich. We lost players regularly because they could not afford to be injured. They clamber up and down a roof to do various jobs and cannot afford that knock on the ankle or the bang on the hand. They can no longer take the chance and miss two weeks' work. As has already been mentioned, if you happen to be medically incapacitated and are on benefits, everything suffers. If we can get a better structure of support from the NHS, these people will be much more likely to carry on. They will also carry on if they receive better help to change their exercise patterns as they get older.

The main thrust of what I am trying to say is that the NHS does not seem to engage in this process of enabling people to maintain exercise in an environment that will encourage them to maintain it. Much of the current thinking about sports science derives from the huge amounts of activity in the private sector devoted to elite-level athletes, who are in effect of another species, both physically and behaviourally, so they are not really my concern here. The fact that Michael Owen may have to go abroad to get his knee dealt with may be an affront to the ego of certain specialists in the field, but it means absolutely nothing to the person who runs out on a Sunday-morning side to play soccer. My concern is about maintaining that sort of exercise.

We are not getting the support and knowledge within those medical professions at the front end. It is down to the NHS to maintain this support, but the structures are not there. People are still told to rest when they have an injury, but that will weaken muscles and shorten tendons, which means that they are more likely to be hurt when they go out again to play. Unless we start to address this by having greater levels of knowledge—this will start with pressure and information coming through from consultants—we will not be able to maintain people's activity at the proper rates. The advantages of greater physical activity will dwindle, and no matter how much we pontificate and tell people to engage in it, there will come a point when they say, "How do I do it? Something has gone wrong with my life. How do I get back?".

I have ignored the fact that it simply hurts to have an injury, and it will carry on hurting if it is not treated properly. But my main experience in talking to people doing various types of sport is that it is often the fear of losing income that stops them playing. If we can somehow address this, we will back up many of the other good schemes. The question that I really want to ask the Minister is—and I think that I will have to ask it again on other occasions, because it is a bigger subject than I initially thought—what is the Government's thinking on bringing sports and exercise medicine much more into the mainframe of the NHS, particularly at the initial point of contact, the GP?

Photo of Lord Crisp Lord Crisp Crossbench 12:34 pm, 7th December 2006

My Lords, I too am grateful to the noble Lord, Lord Colwyn, and indeed to others, for laying out for us what patients are feeling and saying right now. It is their reality that is truly the starting point for our debate.

I am speaking, as I suspect many noble Lords will know, as someone who was privileged to be Permanent Secretary to the Department of Health and Chief Executive of the NHS in England for more than five years. Part of that privilege was the contact with the staff throughout the country and with the heart of the NHS. I note here the comments of the right reverend Prelate the Bishop of Worcester; I agree with him that paying attention to the heart as well as the mind matters.

Based on my experiences as Permanent Secretary and Chief Executive, I shall discuss some of the underlying issues that we are talking about today. Why are all major developed countries experiencing problems with their health systems? Why are costs rocketing? Why is affordability the key question in France, the USA and Germany, and why, in all those countries, are patients demanding more?

The first underlying issue, which I do not want to spend too much time on here, is that we are getting older. As we get older, we face more problems. We have more complex needs and tend to suffer from several problems at the same time—co-morbidities, in the language of the profession. But there are three other issues on which I want to spend more time. To my surprise, I have gained a deeper insight into them from spending the last six months looking at health in developing countries in which these issues are even starker and from which I will, on another occasion, argue that we have something to learn.

First, how can we afford the new technologies? Secondly, how can we turn the raised expectations of the public and the ever growing interest of people in health to good use in managing our health service? To put it another way, how can we as patients and citizens influence decision-making? Thirdly, how do we move upstream to concentrate on the causes of ill health and on keeping healthy rather than giving all our attention to dealing with problems of illness and disease? These are the three issues that we need to address if we are to make progress. I shall make a few comments on each of them.

We have in this country an exceptional biomedical research industry. I believe that 20 of the top 100 most prescribed drugs were developed here, and we are second only to the United States on most research measures. New medicines, new therapies and new technologies are developed every year, and every health system in the world agonises over how to pay for them and whether the sometimes small increments of benefit are worth while.

We have NICE—the National Institute for Health and Clinical Excellence—in England and Wales to help us to assess the effectiveness and cost-effectiveness of these innovations, and to make judgments with the involvement of patients. I am a fan of NICE. We need to evaluate new technologies, which are not all worth while, and NICE has developed some very rigorous methodologies to do this. I am not surprised that, while I was Permanent Secretary, it was the organisation from which most countries most wanted to learn.

I also feel, however, that the current situation is rather absurd. We want new medicines. We need them. I suspect that many of us in this House take aspirins, statins or some other drug regularly. We want to benefit from that science, but we are forced by circumstances to concentrate on putting up barriers to using them.

The drug companies also have a problem. They need to spend millions on sales and marketing to recoup their development costs. In some cases, I believe that as much as 40 per cent of pharmaceutical companies' costs are in marketing and sales. Carrying on as we are will mean a continuing escalation of tension between drug companies and payers and between patients and health systems worldwide, not only in the UK, and an escalation in costs.

There needs to be another way of looking at this—a way of getting alignment between the developers of technology and the payers, a way of ensuring that new research concentrates more on the things we as a society need and that involves more joint development of drugs between payers and researchers, a way of cutting out some of the marketing costs, and a way of achieving greater transparency over research assessments. Sir David Cooksey's report, which was published yesterday by the Treasury, sets out a new way of creating this collaboration. I very much welcome it, and I hope that the Department of Health will be very much a part of that sort of development.

The second issue is in many ways similar and similarly paradoxical. As individuals, most of us spend a lot on our health—on healthy eating, diets, exercise, vitamin supplements and the like. We do take responsibility for our health, but as patients we are too often left feeling helpless, and as citizens we are left feeling disenfranchised. We have a population interested in health that is very often simply in opposition to the people who are, genuinely—I say this with feeling—trying to serve them. We need to break down that opposition and find a way of resolving the paradox that as individuals we take responsibility for ourselves but as citizens we are unable to. I suspect that of the three issues that I am briefly raising here, this is the most difficult.

The third issue is well known. Why cannot we spend more effort on promotion of health and prevention of disease and create a health system that is focused on early health and not on late disease? Here, there are some things that we could do more quickly. Over the past few years many people have put forward the idea that the NHS needs to be taken out of the Department of Health so that it can be managed in a more professional fashion. People are suggesting, for example, a sort of BBC arm's-length five-year agreement between the NHS and the department. Most recently, the idea seems to have acquired some political impetus. Noble Lords will not be surprised to know that I have given it a lot of consideration, and indeed there are attractions. But it is not a simple matter. I have heard a number of over-simplistic ideas put forward. There needs to be very clear accountability for an organisation that, in a few years' time, might spend £100 billion of taxpayers' money.

What is often missed in that debate is that, just as the NHS might benefit from being free of the department, the department would benefit from being free of an over-riding requirement to concentrate on the NHS. A department "for" health could provide the focus we need to concentrate on health—early health—on cross-government approaches to health and ways of tackling the big killers, the diseases of affluence: obesity, inactivity and bad diet. I hope that the Government are considering those very difficult issues as well as how to give more freedom to both the NHS and the Department of Health.

I have set out in as many words as this short debate will allow the issues which I believe we should find more time to examine more often: how to harness research, how to build on people's own interest in health and how to focus on health, not illness. These are absolutely critical in any debate on the current state of the NHS.

Photo of Lord Parekh Lord Parekh Labour 12:41 pm, 7th December 2006

My Lords, I, too, thank the noble Lord, Lord Colwyn, for initiating this very important debate. I would sum up my answer to his question about the state of health of the NHS in one sentence: it is undergoing some convulsions but its life is not in danger. The NHS has made considerable progress while the Labour Government have been in charge of it. If one looks at certain obvious statistics one sees that since 1997 we have gained 50 per cent more consultants, 35 per cent more clinical support staff, 35 per cent more hospital doctors and 34 per cent more GPs. But those are bare statistics. In a very important way there has been a profound cultural change in how the NHS has been constituted in the past few years. Patients feel that they are valued and at the centre of attention and they know their rights, and medical staff are aware that they are accountable to patients and to other bodies for what they do. Many of us who have been around for quite a while have been feeling these profound changes in the NHS. So while I compliment the Government on all that they have done, I want to highlight four or five important issues that worry me a little.

First, the results of the expenditure of resources do not seem commensurate with the amount spent. For example, GPs have been given very generous contracts—and I spend all my time among friends and relations who are GPs. On average, they earn about £100,000 to £125,000 a year, a figure which we professors simply envy. I do not begrudge them at all, but I think that in return for that one could expect that the range of services would be wider, the premises more efficient and the services offered to patients administratively more competent. I do not see those changes. And it seems the same with NHS trusts. They have been given a considerable amount of money and freedom to run their affairs but their administrative and management capacity, especially in matters financial, has not kept pace with the amount of responsibility they have been given. I do not know how much attention is being paid to ensuring that the people in charge are suitably trained.

Secondly, there are two conflicting considerations on the reorganisation of hospitals which are not easy to balance. It is right that the latest medical technology should be concentrated in a few centres, for obvious professional as well as financial reasons. It is also important that there should be supra-regional accident and emergency departments concentrated in certain places, and, pari passu with that, some should be downgraded. While that is necessary, it is also important to bear in mind that it conflicts with patients' preferences and needs. Patients do not feel safe without access to an accident and emergency department that they can reach within a reasonable time. They also prefer to have babies in local maternity units. It causes anxiety to downgrade such facilities to a single midwife-led unit. We therefore have to find ways of balancing the need to concentrate medical and professional resources in certain regional centres with the need to provide local centres. The Government seem to think that smarter communication might solve the problem but I do not think that it is as simple as that. These two considerations have to be reconciled in the light of local circumstances. In taking such decisions, a great deal of attention should be paid to the views of patients, the public and doctors. They should be involved in taking decisions of this kind.

My third concern has to do with the independent sector treatment centres. I am not against the private finance initiative but I have some grave anxieties. In this case, they are poorly integrated into the NHS and do not train doctors in the same way as hospitals. There is too much reliance on foreign—in some cases, overseas—staff. We do not seem always to get value for money. These independent centres also enter into long-term contracts which are not easy to change. I would suggest that, although they are necessary to deal with the backlog, our overall strategy should be to concentrate on expanding NHS facilities rather than relying on centres of this kind.

Fourthly, as the noble Lord, Lord Crisp, said, rationing in one form or another is insuperable. But we must bear in mind that there is an unholy alliance of drug companies, populist media and some groups of politicians who seem to want to make sure, sometimes against the advice of NICE, that certain drugs that might not be recommended because they create a certain amount of popular scare should be widely available. NICE took a very firm stand on, for example, the flu drug Relenza and faced down Glaxo, which had threatened to leave the country. Decisions on rationing are inevitable. Rather than the Government leaving these decisions entirely to NICE, it is very important to involve medical staff who could explain why certain decisions have been taken.

Finally, noble Lords will expect me to say something about the important issue of the ethnic minorities. Their representation on NHS trusts falls far below their number in the country at large and their presence in the profession. How many chief executives are drawn from ethnic minorities? How many people from ethnic minorities are on NHS trust, foundation trust and PCT boards? I would like to know how many members of the NHS Appointments Commission are drawn from the ethnic minorities.

In many areas we are beginning to find that there are redundancies and the contracts of doctors and nurses are being terminated. People who have been in training for some time are being told that they may not be able to get jobs commensurate with their qualifications. Some of my close consultant friends tell me that the burden of redundancy is likely to fall disproportionately on ethnic minorities. I should like to be reassured by the Minister that that is not the case and that, should it happen, there will be enough provision to ensure that such decisions are countermanded.

I have full faith in the Minister and the Secretary of State for Health but suggest that the style of administration and the mode of decision-making they have inherited during the past 10 to 15 years need to be radically changed. The NHS is a Labour creation and something to which the party has been strongly committed. It would be a great pity if people felt that they could not trust the Government or the party with the safeguarding of the NHS.

Photo of The Earl of Northesk The Earl of Northesk Conservative 12:50 pm, 7th December 2006

My Lords, like other noble Lords, I congratulate my noble friend Lord Colwyn on securing this important debate. Notwithstanding that it is a huge—some might say monstrous—subject, I intend to focus on the national programme for information technology.

At the outset I should make it plain that there are few more fervent adherents of IT than myself. To that extent, and irrespective of the raft of difficulties that have plagued the programme over the past few months, I accept without question that effective use of IT is an essential part of reform of the NHS and the future of healthcare in the UK. But what matters here is the "how". At the heart of this is recognition that a required, even essential, outcome of reform is improved focus on the needs of the user—that is, the patient. Indeed, NHS Connecting for Health appears to accept this dictum. Its guide to the national programme states:

"The new era dawning for the NHS involves modern, sophisticated IT which will provide solutions to the problems that have dogged the NHS for years. In tandem with other programmes, a much more patient-centred NHS will emerge, able to deliver on patients' needs at times and places to suit them".

It adds: "Importantly", patients,

"will be able to take more control of their health and treatment, with information to make choices more readily available".

That is all good and well. But a top-down system driven by centralised control and targeting—the Government's current proposal—is antipathetic both philosophically and practically to the concept of giving patients more control of their health and treatment. Nowhere is this dichotomy more apparent than in the Government's approach to the issue of confidentiality of patient data.

As your Lordships will be aware, the linchpin of the new system will be electronic NHS care records compiled for each of England's 50 million patients. While the full details of each individual record will be retained locally where care is delivered, it is also intended that a summary record will be automatically "uploaded" to the NHS spine, characterised by the CfH as a,

"core data storage and messaging service".

As such, this database will be accessible, albeit at variable levels of authority, by not only the 300,000 or so NHS staff who have been issued PIN-coded smart cards so far but also by non-medical authorities provided that their requests for access are judged to be in the public interest. It should be borne in mind that summary care records will comprise data that would fall within the category of "sensitive" as defined in the Data Protection Act, not least because at last month's annual meeting of the Care Records Development Board the decision was taken in principle that there should be a "single holistic record" of patient care, encompassing not only health records but social care information. In effect, it does not stretch credibility to suppose that the spine represents the health and social care records arm of the national identity register.

I freely admit that, in some ways, the principle is sound. It is in the interests of patients that, within an efficient and well run computerised system, their records should be readily accessible wherever and whenever they are needed. But such a system should not be devised at the cost of stringent privacy safeguards. Fundamental to this is whether patients should have a right to opt out of having their data uploaded to the spine. After all, under the second data protection principle, it is a statutory requirement that sensitive personal data,

"shall be obtained only for one or more specified and lawful purposes, and shall not be further processed in any manner incompatible with that purpose or those purposes".

In reality, the whole issue of the patient opt-out has been something of a farce. John Hutton stated:

"Patients will have the right to specify that detailed information recorded at the point of contact with the NHS should not be available to other NHS organisations".—[Hansard, Commons, 2/11/04; col. 176W.]

In similar vein, the NHS care record guarantee of February 2005 states:

"From the outset this new system will enable you to control whether information in electronic records made about you by the organisation providing your care can be seen elsewhere in the NHS", adding, without a hint of irony, advice to patients that they should:

"Only give others access to records about you if you are sure it is necessary".

At the very least these comments imply a right for patients to opt out of the spine.

However, in stark contrast to this, the CfH's output-based specification published in 2003 contained the warning, presumably to potential IT suppliers, that there would be:

"High sensitivity, both actual and political, of Spine data for which no patient consent has been obtained ... A patient will not be entitled to refuse to make their personal data available to the Spine. Data about all patient events may be routinely communicated to the Spine without the consent of the patient".

Also, a week ago the Department of Health issued a press release indicating that it would not permit those who had sent in a coupon provided by the Guardian to opt out of the spine.

The confusion and muddle of the situation is perhaps bad enough but, as your Lordships will be aware, a recent survey has revealed that 80 per cent of GPs fear that the confidentiality of their patients' medical records will be at risk if they are uploaded to the spine. This is not mere supposition. According to the Sealed Envelopes Risk Assessment Project report commissioned by the CfH, the security and confidentiality of patient data would be best achieved by a "sealed envelope" design, with data held locally rather than uploaded to the spine. Moreover, as evidenced by the YouGov poll on ID cards in last week's Daily Telegraph, there is growing public discomfort with the accuracy, reliability and confidentiality of centralised databases.

By any measure, the trend of public sentiment in this area is towards a more patient-centred approach. It is therefore regrettable that, notwithstanding the soothing rhetoric to be found in some of the policy development literature, the Government seem to be lapsing back into an almost Stalinist mindset, an enforced centralised diktat delivered with all the subtlety of the playground bully. It is as if the Government are attempting to articulate a new orthodoxy here, one which has uncomfortable echoes with the anxieties expressed by the Information Commissioner, Richard Thomas. He has highlighted the NHS scheme as part of a trend where:

"As official databases grow in size, there is a corresponding thrust to join up all the separate holdings".

Henry Porter put it succinctly in the Observer last weekend. He said:

"The implication of these systems and databases is that we all have something to hide. It follows that a condition of the new citizenship that New Labour has dreamed up for us is that innocence must be routinely demonstrated in a process of daily positive vetting and if this entails the loss of freedom and privacy, well, that is just the price we must expect to pay for security".

The extent to which the NHS spine may or may not be part of this trend is a matter of conjecture. Be that as it may, there is considerable legitimacy in the expressions of concern of both patients and GPs. For my part, I would heartily recommend that anyone who shares those concerns should visit www.nhsconfidentiality.org. The Government really do have to make up their minds whether the avowed determination to make the NHS more patient-centred is actually delivered or just so much hot air. A good start would be to allow patients the right to opt out of the spine.

Photo of Lord McKenzie of Luton Lord McKenzie of Luton Government Whip, Government Whip

My Lords, I am sorry to interrupt the noble Earl but this is a time-limited debate.

Photo of The Earl of Northesk The Earl of Northesk Conservative

My Lords, I have finished.

Photo of Baroness Murphy Baroness Murphy Crossbench 12:59 pm, 7th December 2006

My Lords, we have many opportunities in this House to consider the NHS but, like many others, I thank the noble Lord, Lord Colwyn, for raising this debate at a time when the media are full of their favourite scare stories and so many Members of the other place are having such sport in their own constituencies. There is no greater gift to Back-Bench politics than a nice hospital-closure scare. However, first let me declare my interests as chair of council at St George's, University of London, and as a board member of Monitor, the NHS foundation trust regulator.

I had an opportunity in the debate raised by the noble Lord, Lord Rea, only a couple of weeks ago to express my strong support for government policy in pressing on with the increased independence of providers, plurality of provision and encouragement for private sector competition. I also strongly support the emphasis on increasing productivity and cost-effectiveness.

It is a sad fact of life that, as currently structured, the only time the NHS undertakes necessary service restructuring and modernisation is when it is short of money. The current proposed reconfigurations are not the outcome of a cost-cutting exercise; rather, they are changes that should have been put in place years ago but were deemed to be politically undeliverable at the time. My noble friend Lord Crisp will remember well his reaction, and that of Ministers, when my strategic health authority wanted to join up two tiny primary care trusts in north-east London to match the borough boundaries. The notion that we might propose to reconfigure large services, such as maternity services, which needed doing very badly, or whole hospitals was out of the question.

I too am attracted to the notion that we should get some kind of distance between the Department of Health and the overall management of investment in the NHS. Perhaps we might like to look at the model of the Higher Education Funding Council for England, which purchases higher education places but leaves a measure of independence to providers. That is quite a good model.

My concerns about the proposed reconfigurations are whether political courage will be sustained long enough to implement the necessary changes—time and again I have seen Ministers cave in to Back-Bench pressure—and whether the service cost and quality information is sufficiently robust to allow sensible decisions to be made. The detailed data are not there, although I believe they could be fairly quickly. At Monitor we have been doing some pilot work on service-level economics that provides some fascinating insights for the participating foundation trusts and allows far better strategic planning of future service delivery and cost improvements. Hospitals are not homogeneous entities; neither are community services. Even the worst basket case of a DGH—and there are some—contains some service gems. Ensuring that they survive and flourish will be a challenge. What progress is being made to help NHS trusts move their accounting systems towards service level costings? If none, on what basis are decisions being made?

I turn to budget raiding by strategic health authorities, the age-old, lazy way of balancing budgets in the NHS in order to prop up the voracious acute hospital sector. That is Enoch Powell's phrase, by the way, not mine. It is happening to education and training budgets and to mental health services. My noble friend Lady Meacher mentioned this issue in her excellent maiden speech on the gracious Address. Mental health trusts generally stay within budgets when other acute hospital services do not. We heard her say that nearly £4.6 million is coming out of the revenue budgets of East London and the City Mental Health Trust, which serves the most needy area in the UK. The noble Lord, Lord Layard, has set out for us today the huge need in mental health outside the existing mental health trusts. That need will not be met by the current way of dealing with mental health budgets. A survey carried out by the Sainsbury Centre for Mental Health in July found that nearly two-thirds had been asked to cut their budgets to cover overspending in other areas.

The second area being raided is education and training budgets for nursing, midwifery and allied health professionals. Over 10 per cent has been cut from training budgets this year, although it is much worse for universities in some areas, notably the east of England, and strategic health authorities in London and the south-central and south-west regions, which are also predicting larger reductions for 2007-08.

The current numbers of unemployed newly qualified nurses are due to NHS posts suddenly being frozen for financial reasons, not because of any serious reconsideration of staffing requirements or oversupply of graduates. If the numbers of new students continue to be reduced, that will lead inevitably to a boom-and-bust scenario even worse than we experienced in the 1990s. We have seen that cycle before, and it is coming around again because of short-termism. What are the Government doing to ensure that this all too easy budget raiding is stopped?

Finally, I come back to mental health services, particularly those for older people. That is my own speciality, and I have therefore been circumspect in talking about it in this House. It is clear from work done by Professor David Challis's group at the PSSRU in Manchester that progress on the five year-old National Service Framework for Older People has been very slow. Many community teams still lack core team members, such as psychologists, and indeed social work input has gone down in the past five years. Where protocols for referral exist, they are rarely used by GPs, and the single-assessment process, which we all wanted and pressed for—indeed, some of us were running them back in the 1980s—has developed into a bureaucratic nightmare that has not led to real service improvements. One-quarter of services have inadequate community resources to sustain people at home.

Management focus on these services is extremely poor, even though the patients often have the most complex family needs. Adult general psychiatry services have mopped up the extra investment in mental health so that older people's services therefore remain old-fashioned and largely bed-bound, with resources locked up in the wrong place. It is time we looked at how we can get the balance right when most of the mental health admissions to hospital are for people over 65. What are the Government doing to promote better services for older people with mental health problems?

Photo of Lord Selsdon Lord Selsdon Conservative 1:06 pm, 7th December 2006

My Lords, strangely, I find healthcare one of the most interesting political, economic and social subjects in the world, although 10 years ago I would never have believed that. I have tried to find out more about this subject. I know that as I stand here and look at the noble Lord, Lord Warner, he will behave with his customary, loyal, government box-wallah attitude. He will swish ideas aside with a flywhisk; in the midst of a monsoon, he will say, "It's a lovely sunny day". For that I admire him.

In this case the noble Lord is, in a way, correct. For the first time in my life in this House, everyone believes in the National Health Service as a national asset, whereas I feel that it might be a national obligation or a liability. If healthcare is so important, why do we spend our time sniping at the system, at those in it and at those who wish to use it, and find problems? If we looked at the system another way, we could say—I shall repeat some of the things I have said before—how magnificent it is that we have a million people employed in the National Health Service when our population is only 60 million. Germany and France, with a combined population of 120 million, have a million people working in their health services.

I used to say that we had more people per bed, but more health people per person, than anywhere else. Do we need all these health people? Is the market big enough for them? Yes; the market for healthcare worldwide is enormous, and our National Health Service could effectively be quite a remarkable nationalised industry if we took control of it away from government. I am agreeing here with the noble Lord, Lord Crisp, and, to some extent, with the noble Baroness, Lady Murphy.

We find, to our surprise, that the NHS does not make any money. We find, too, that we are mortgaging our souls for the future. I was a director of a construction company which built many hospitals. We lost £50 million and closed down our building business because we could not make any money out of it. The only people who did were those who knew they had the security of a long-range cash flow provided by the Government. It was called PFI. On the stocks now, waiting to be built, are another £12 billion to £15 billion of government PFI projects. Drop the PFI. It was last year's story. We have to look for another way. What is the problem? It is one of cash flow.

Hardly any hospitals seem to have room—and yet we have too many beds. We have 192,000 beds—fewer than in other countries—but we do not need them all today. Our problem is that there is a lack of progress in waiting lists and things of that sort. The healthcare business is a normal, simple system, like taking your car in for a service. You need diagnosis—diagnostic centres, as my noble friend said. Diagnosis is not too difficult. You need a diagnostic centre costing about £5 million and maybe the 168-slice scanners you can buy now—unfortunately we do not make EMI scanners any more; we have to buy them from GE or Siemens—and then you can provide service 24 hours a day.

If you want to be diagnosed these days, you go to your GP first, which may take two or four weeks, although it is getting shorter, and he then tries to get you a diagnosis. First, you have to go to a consultant, which takes another 43 to 47 days and then he tries to get you a scan which can take another 40 to 43 days. Then back comes the report—that takes a long time—and, finally, you go on the waiting list.

There is a pent-up demand for patients who are economically beneficial to the National Health Service. Hospitals could treat more but, somehow, the waiting lists remain long. I have on previous occasions asked the Government how long the waiting lists are for each aspect of elective surgery and think I shall have to put down a number of Questions for Written Answer. There is nothing wrong that organisation cannot put right. We have quality here and we have more than enough patients. The financial aspects need looking at again.

Why do we differentiate between the public and private sector? We are all private individuals who want a good health service. We do not mind where it comes from, but we would feel more confident if it came from the state and probably even more confident if it were taken out of the control of government.

I have spent the past two years going round France, Germany and Switzerland, looking at the opportunities there may be. The noble Lord, Lord Crisp, pointed out that each country has similar problems. But some are efficient, and efficiency depends to some extent on cash flow and the reliability of money. In general, a badly run public hospital is worth half a year's turnover, while one that is well run is worth one year's turnover. A well run hospital would probably have earnings of perhaps 15 per cent EBITDA or 2.5 per cent of turnover and could finance its own development. I do not believe we have a single hospital that is economic, yet we have a solid base of a million people with good education and training. The drug companies in general are foreign, but we are one of the most attractive places in which to invest for drug development, not necessarily for drug testing.

The basis is sound, provided that the organisation and structure are changed, but please can we take it out of the hands of both the potential Conservative Government and the current Labour Government?

Photo of Baroness Masham of Ilton Baroness Masham of Ilton Crossbench 1:12 pm, 7th December 2006

My Lords, there is no doubt in my mind that the National Health Service is a high priority on many people's agendas. The sister of one of my Cross-Bench colleagues came up to me in Yorkshire last Friday, without knowing that this debate was about to take place, and said "I hope you are supporting the NHS. We need reliable, good services near our homes". As many community hospitals are having to cut beds and some are closing, this is a worry across the country for the increasing elderly population. I thank the noble Lord, Lord Colwyn, for calling attention to the current situation in the NHS.

On Sunday evening, a friend telephoned me from Wiltshire, south of Salisbury. I told her about this debate and she said "You must speak about doctors' out-of-hours working". This is not the first time I have mentioned this, but last time I referred to Yorkshire. My friend told me that her husband, a tetraplegic who had broken his neck, had become ill one night after retiring when his catheter blocked. His wife called the out-of-hours doctor. She sat with her husband all night, waiting. The doctor telephoned at about five am—the doctor was speaking from Birmingham. Is this a service to be proud of?

This brings me to the need for safe A&E departments that can be reached in a reasonable time. Should people who are severely disabled use an out-of-hours doctor or an A&E department? They really do not know. The Government claim to be bringing care closer to the people, but they are planning to take local A&E and maternity departments further away from them. People do not feel safe without vital services they can reach before it is too late, especially in rural areas. I agree that there should be some centres of excellence for special conditions, but these should be supra-regional hospitals.

During the summer, I was invited to a south London GP's surgery. The doctors asked me to bring up some matters. I have already sent them to the noble Lord, Lord Warner, but have not yet had a reply, so I take this opportunity to mention them to your Lordships.

Until recently, a patient was referred by a GP to a consultant specialty in the hospital. Once the patient had been seen in the specialist clinic, if it was deemed that he or she would benefit from a different consultant specialist, the first consultant would simply refer the patient to the second consultant. This was more efficient; it cut down on time and NHS spending. Above all, it was best for the patient. Recently this practice has been stopped. Now, if the first consultant feels that the patient will benefit from another specialty opinion, he or she will refer back to the GP and ask him or her to refer the patient, from scratch, to a different consultant.

For example, a GP may feel that a patient has a knee pain problem and refers him or her to an orthopaedic consultant. Once at the clinic, the consultant feels that the knee pain is a nerve pain, not a bone or joint problem. He or she refers the patient back to the original GP, with a letter asking the GP to refer the patient to a neurology consultant. This, effectively, is an increase in bureaucracy, red tape and waiting time, leading to more NHS spending. In essence, the GP is billed twice for one patient, as the referral has been duplicated. Above all, the patient suffers from the delay. GPs at the Faccini House surgery at Morden in Surrey feel that this is a ludicrous strategy. Is it to do with targets? Why complicate the life of ill patients? They may have to wait months for a second referral. This is not what the patients expect.

Last week, the Times reported that Britain would be dangerously reliant on other countries to supply life-saving bird flu vaccinations should a pandemic break out. So far, it is reported that Britain has ordered 3.3 million doses of anti-H5N1 vaccines from two companies, based in Italy and the Czech Republic. A vaccine that would immunise the population cannot be produced until that specific virus strain emerges. Will Britain be able to produce its own vaccine?

There are so many demands on our health service, but one that does not cost much money and saves life is the need to enforce hand-washing by doctors and nurses between patients to stop the spread of hospital infections. They must get into this all-important routine. Downgrading of any service will only increase the danger that infections will win in the end.

Photo of Lord James of Blackheath Lord James of Blackheath Conservative 1:19 pm, 7th December 2006

My Lords, many noble Lords have spoken with passion and conviction about individual aspects of the National Health Service which concern them. Those concerns can be addressed only if they are set in the context of a stable, securely financed, well managed and continuing NHS as a body corporate.

We come to this debate in an almost complete data vacuum, with hardly any information before us by which to assess the current status of the National Health Service. All we have to rely on is a brief document entitled NHS Financial Performance: Quarter 2—2006-07, which is available in the Library. I have arranged—because I think it is very important—for it to be broken out from the NHS website. A lady there can e-mail it directly to noble Lords' computers at any time they wish. I recommend that all noble Lords read it. It is all we have to rely on.

I read the document in the context of comments which I made during my maiden speech two weeks ago, when I noted that it was claimed that the NHS would have a deficit of £650 million this year. I wanted to see whether that figure would be confirmed today. In fact, the report gives us a choice of three figures for the deficit in the current year. The £650 million figure receives no mention. The report refers instead to a deficit of £883 million, which is said to be the increased figure—it implies that it was the figure quoted on the previous occasion, but it was not. The report then states that the deficit will be only £90 million for the current financial year. It is a remarkable conjuring trick which needs some thought. The figure of £90 million comes after the introduction of the write-back of a contingency of £350 million. We have no idea what that originally stood for, but it has now been thrown in. There is no reference yet to any consequences arising from the intended redundancy programme for 9,000 staff, which was announced earlier this year. The report states quite clearly that only 903 redundancies have been achieved so far—well, only another 8,000 to go. This is of concern, because it is said that the 8,000 redundancies will produce a saving of £250 million to the NHS for the remainder of this year, but we have no idea what, if anything, has come from the first 903 redundancies, which include 187 senior clinical staff. There is no reference, either, to what the cost of the redundancy programme has been or will be.

How do we get from £90 million to £873 million, which is now claimed to be the deficit? We take the £90 million and add back the £350 million, which comes to £440 million. We put in what we will assume to be the contingency for £250 million of benefit to come from the remaining 8,000 redundancies to be achieved, which takes us up to a figure of £690 million. I assume that the difference between £690 million and £873 million must be the extra cost of achieving the redundancy programme, although that figure seems a little light.

However, when we read on, the NHS report states that the deficit for the year will not be the £650 million or £873 million which we expected; it will be £1.173 billion. However, no explanation is given of how that figure is reached. We have therefore jumped through three figures in succession without any explanation. This simply will not do. We face a situation where the NHS is clearly playing around with the old problem of contingencies and provisions which magically bounce in and out of the accounts. We need clearer discipline in how these contingencies are applied. Contingencies which are carried over from a previous year are a great evil and an incitement to sloppy managers, who can then write them back into the accounts and pretend that they have achieved positive savings in running levels of overhead. However, it will have done nothing to the running rate of overhead or the funding burden for years to come.

The Chancellor of the Exchequer should outlaw anything but current-year contingencies straightaway, and he has a very good authority in Jesus Christ on his side for doing so. What else is the parable of the unjust steward or the parable of the talents? That is well worth thinking about. If the Chancellor feels a little uneasy about it, he is in good company.

As for the rest of the report, we are left in a vacuum. We should have seen a positive benefit of £500 million from this year's redundancy programme. As I said in my maiden speech, I suspect strongly that that has already been conjured away to cover some hitherto unidentified and unadmitted black hole elsewhere in the NHS.

We are advised by the Office for National Statistics of a 1.3 per cent decline in the National Health Service's productivity in every one of the nine years in which this Government have been in power. That is a cumulative decline of 10 per cent. Through the same period, the funding of the National Health Service has risen from £34 billion to a current figure of £72 billion—an increase of 112 per cent—and it is scheduled to rise by another £22 billion, meaning an aggregate increase of £187 billion, in the next two years.

Those great companies Rover and Railtrack, and even the company which ran the Millennium Dome, all reached the point at which the National Health Service finds itself today. Nobody ever said, "It is time to stop and ask where this really is". It is outrageous that noble Lords present today will not have the opportunity to learn precisely where that deficit is or what the running rate of cash going into the next financial year will be; moreover, they will not be given assurance that it is containable within the present fiscal policy and will not require swingeing new levels of tax to cover it.

Today's Times states that the Chancellor of the Exchequer is seeking a new task for his "clunking great fist". I have one to suggest to him. He should summon a meeting of the Permanent Secretaries at the Department of Health and the Treasury and put together a small task force to assemble key information, which can be consolidated into a balance sheet and trading account for the NHS, and give us a definitive assessment of the deficit for the year. They should have it done by some time on Sunday afternoon. The Cabinet can then approve a Statement to be made to both Houses of Parliament on Monday morning and lighten our darkness.

Photo of Lord Walton of Detchant Lord Walton of Detchant Crossbench 1:27 pm, 7th December 2006

My Lords, having graduated in medicine 61 years ago, I judge that I am the only contributor to this debate who was practising medicine in the UK before the National Health Service began. I was proud to work as a consultant, and later as a clinical academic, in the NHS and I have been one of its fervent supporters.

There has been a proud record of achievement during the past 60 years, which I think everyone working in the health service acknowledges. When I gave the BMA lecture in 1996 to celebrate the passing of the National Health Service Act 1946, I pointed out that the number of consultants and GPs in the UK was about 25 per cent of the number in other relevant countries. I urged the Government of the day to consider the possibility of hypothecated taxation to produce an increase in the funding of the NHS, which had been long awaited. I had urged that over many years, but no Government had listened until the current one—I pay credit to them for doing so. They put a 1 per cent surcharge on national insurance, and the money has thereby increased.

However, even now, the number of GPs and consultants, compared with our competitors in Europe, is still about 50 per cent of the ideal. That is of course unachievable, because the finances of the NHS are finite, as my noble friend said so clearly. I remind him that, some 30 years ago, my former colleague the late Dr Henry Miller urged, in a public debate with Enoch Powell, that the funding and administration of the NHS should be handed over to an independent corporation—the idea is not new.

When I gave that lecture, I pointed out to the BMA that, in the 50 years before I spoke, I had lived through 14 reorganisations of the NHS. Within the past 10 years, I have lived through 11 reorganisations. Frankly, there have been times when the NHS has been afflicted by a disease called "reorganisationitis", for which the only proper therapeutic action would be for the Government to take their hands off and not embark on yet further reorganisations. I exempt from these strictures the long-awaited and very reasonable proposals on A&E departments. As the noble Lord, Lord Rodgers, said, if one is to treat stroke properly as an emergency, that kind of organisation will be absolutely essential.

The Government have embarked on producing a bewildering plethora of commissions, authorities and other organisations within the NHS which have, in turn, spawned a forest of new acronyms to delight the heart of management consultants. Those bodies have been at times established then abolished, then merged and reconstructed, so that many people are quite unaware of exactly how the NHS has been advised and managed. It is time for a period of stability.

I pay tribute to the health service for having funded over many years a large number of clinical academic posts in our universities. That is a major achievement that has improved training and patient care, because today's discovery in basic science brings practical development in patient care. The Cooksey report, to which the noble Lord, Lord Crisp, referred, is going to be a major step in that direction. But a formal agreement was reached several years ago between the universities on the one hand and the NHS on the other that a funding stream called SIFT—the service increment for teaching—designed for the training of medical students and nurses would be ring-fenced and preserved. Quietly, without consultation, that ring-fencing has been removed within the past two years. The result has been a devastating cut in the education budget for medical students and nurses at a time when medical student numbers have been sharply increased because of the need for more doctors and to reduce reliance on immigrant doctors.

Leicester Medical School has been threatened with a 20 per cent cut in its academic budget. It may be reduced to 10 per cent by negotiation, but the situation is still serious. More serious still is the fact that the new medical schools, assured in 2001 that their SIFT money would not be raided, have now been told that it is no longer ring-fenced. For example, the Peninsula Medical School faces a possible deficit of 15 per cent, with devastating effects on its training programme.

I refer to another difficulty. In the NHS there has been a massive development, much-awaited, of specialist nurses who have specialised in looking after patients with epilepsy, Parkinsonism, stoma care, multiple sclerosis and many other diseases. They have played an enormously important role and have often reduced the need for in-patient admission for patients whom they are looking after in the community. Now the PCTs are cutting the number of specialist nurses or diverting some of them into standard patient care because of financial constraints. I know that the Minister will say that the employment of specialist nurses is a matter for the PCTs, but I believe that governmental pressure to underline the importance of that group of people is vital. I refer to the point that the noble Baroness, Lady Masham, made. I have a consultant friend in a major London hospital, one of my former trainees, who has been told that he is no longer allowed to hold a follow-up clinic or to refer patients to another consultant in the same hospital. This is not the NHS that I was proud to serve.

Will the Government please exercise restraint, stop stirring the organisational pot and allow dedicated health professionals to get on with the job of looking after patients without being continually distracted into more non-clinical, administrative, non-productive activity?

Photo of Lord Graham of Edmonton Lord Graham of Edmonton Labour 1:34 pm, 7th December 2006

My Lords, it is a great pleasure for someone such as myself to have the opportunity to speak in this important debate. I am very grateful to those colleagues in the House who have spoken and who have demonstrated their eminence and their knowledge of the National Health Service.

The title of the debate calls attention "to the current situation", which means not only those with expertise and involvement but the recipients of the service. If I speak for anyone it is as a consumer of the National Health Service; I do not pretend to argue for or against on the many valid points that have been made, many of which I respect. But in an organisation that seeks to serve more than 50 million people, it is inevitable that in its organisation and service many people are hurt or aggrieved at the manner in which they are treated. That is the case throughout the country.

I accept that with all the instances that have been raised, which are blemishes on the record of the NHS, there is probably a case to answer—and the Minister will do his normal competent job in that regard. But I ask noble Lords simply to look at my face. Right by my cheekbone, although noble Lords may not be able to see it very well, is a scar which I have borne since the age of 10, when I lived on Tyneside. My mother sent me to do some shopping. On my way back, half way up a street called Rye Hill, I was set upon by two boys, who said, "Give us what's in that bag". I said, "No", whereupon one of them pulled out a knife and stabbed me. He missed my eye by a fraction of an inch. I was taken to the local doctor, who inserted clips into my face, and I was healed. My mother was trying to keep our house together with a husband who was not only on the dole but on the means test, with five children of whom I was the eldest. Seven of us were living on 37 shillings a week, and she was asked to pay three guineas, which of course she could not afford. So for two years she paid sixpence a week to the doctor to pay off the bill. That was the situation in general at that time.

At another time, I lay on a hillside in Wales, the subject of friendly fire—having been shot down by a burst of fire from Bren guns—with my intestines in my hands. So I have had experience of the health service before it was the National Health Service.

Later on in my life, my wife suffered from an inherited disease called myotonic dystrophy. Sadly, as a result of that, she died on Boxing Day less than 12 months ago. Our two sons inherited the disease. So we have a family of a man, his wife and two sons—and I say, "Thank goodness for the National Health Service!". I have a perspective on what it was like before the service existed, which I think many people who criticise the service sadly cannot judge. It is not that they have it too easy, but they have not had the experience to appreciate it.

I was delighted to hear my noble friend Lord Walton refer to his experiences. I was at a function the other day where a lady was asked where she was from—and she said, "The Royal Victoria". I said, "You mean the infirmary", and she said, "Yes". On Tyneside the RVI was known simply as "the infirmary" rather than the Royal Victoria Infirmary. In every community there is such a place—in Leeds it is St Jimmy's and in my part of London there is Whipps Cross—where the hospital is the saviour for so many people. In my life, I have had two DVDs

Noble Lords:

Oh!

Photo of Lord Graham of Edmonton Lord Graham of Edmonton Labour

My Lords, I mean two DVTs—but that is a record of a kind! I have a prostate condition and am a diabetic. One of my sons had ulcerated colitis and went to Barts Hospital, which is where they discovered the inherited disease. To those who criticise the National Health Service I simply say that they may by all means do so. I noted that the noble Lord, Lord Selsdon, said that far too often the health service is the subject of sniping and carping. People who have a genuine grievance do not seem to appreciate that it will be solved by the Minister and his team, if they work together as a team. I make no political point in saying that when the health service was established there was a need for it. That need has grown over the years. The health service serves the people of this country very well. I say to the Minister and his colleagues, "Keep going and more power to your elbow". To those who do not believe it, I simply say, "Oh ye of little faith, lift up your hearts; tomorrow we shall win".

Photo of The Countess of Mar The Countess of Mar Crossbench 1:40 pm, 7th December 2006

My Lords, that was a very salutary speech. Like other speakers, I am most grateful to the noble Lord, Lord Colwyn, for instigating this debate today.

I propose to restrict my speech to two subjects, both of which are described by their detractors as figments of patients' imaginations, so I hope that noble Lords will bear with me. As a result they suffer a lack of establishment support and a serious paucity of funding.

It is only very recently that we have debated the subject of homeopathy. I am raising the subject again today because our homeopathic hospitals are endangered. I do not intend to return to the pros and cons of homeopathy itself. There are five NHS homeopathic hospitals in the UK: in Bristol, Liverpool, London, Tunbridge Wells and Glasgow. All have been part of the NHS since its inception in 1948, though several have existed for over a century.

These consultant-led services are staffed by fully qualified doctors, nurses and other professionals who have additional training in homeopathy and other complementary therapies such as acupuncture. As is usual in the NHS, patients are referred by their GP or specialist. Homeopathic hospitals are a unique asset to the NHS for several reasons: they offer patients genuine choice of treatment by providing evidence-based, highly professional complementary medicine; although small, they are highly innovative—for instance, acupuncture for pain and complementary cancer care, both now widely available in the NHS, were pioneered by the homeopathic hospitals—and they have made important research contributions, such as researching "effectiveness gaps", conditions for which GPs lack effective treatments, and the outcome and cost-effectiveness of complementary medicine.

The NHS homeopathic hospitals help many patients who have been failed by other parts of the NHS, including those suffering from "effectiveness gap" conditions, complex chronic problems, or conditions difficult to label and for whom conventional medicine has proved ineffective or has associated serious side effects. The treatments they offer are complementary to, and integrated with, conventional medicine. Their practitioners are qualified health professionals working within the NHS and communicating with NHS colleagues. Surveys consistently show that 70 to 80 per cent of patients report benefit and around 90 per cent are satisfied with their treatment.

In the past, Governments have reaffirmed their commitment to homeopathy in the NHS, a commitment made originally by Aneurin Bevan. Now, local NHS commissioning and the financial crisis currently affecting the NHS have placed these unique assets at risk. Decisions to refuse funding, which affect patients' ability to choose their treatments, are being made to satisfy short-term financial needs by NHS commissioners with little understanding of the value the hospitals provide. There is concern that commissioners are encouraged in this by a series of high-profile, hostile leaks to the media. These include a leak of a draft of the Smallwood report by the distinguished economist Christopher Smallwood, who highlighted the potential for complementary therapies to provide cost-effective NHS treatment options, which was commissioned by the Prince's Foundation for Integrated Health. The leak appeared on the front page of the Times on 25 August 2005. There was also a letter attacking complementary medicine, which was sent to chief executives of all primary care trusts and leaked on 23 May 2006—again, on the front page of the Times.

While the long-term impact will be the irreversible loss of patient choice, which will leave many patients stranded—in particular, those whom conventional medicine has failed—the amounts of money involved are tiny. West Kent Primary Care Trust wishes to cancel its contract of £160,000 a year with the homeopathic hospital in Tunbridge Wells. This contract accounts for 50 per cent of the patients seen at Tunbridge Wells and its loss would make the service unviable. Local reaction has been very strong: patients have already delivered a 3,000-signature petition to the primary care trust.

Other homeopathic hospitals are facing similar decisions by PCTs seeking to reduce costs. This is being done in the absence of a cost-benefit analysis. Have the additional costs that will be incurred treating patients elsewhere in the NHS been calculated? Because of the fragmented nature of NHS commissioning arrangements, no one body has oversight of this or of the potential consequences of the irreversible loss of these small, unique units that punch far above their weight in terms of patient care, innovation and research.

I ask the Minister whether Her Majesty's Government are still as committed to the continued success of all four hospitals in England, and, if they are, what measures Ministers propose to protect them. Additionally, I seek an assurance from the Minister, already given to the House by two of his recent predecessors, that patients who have started a course of treatment paid for by the NHS, and which is clinically effective, will not have their funding withdrawn by reason of cost alone.

I hope that the Minister has received a copy of the report, published at the end of last month, entitled Inquiry into the Status of CFS/ME andResearch into Causes andTreatment. A group of MPs and Peers, of whom I am one, led by the Minister's honourable friend Dr Ian Gibson MP, read and heard a great deal of evidence from patients, carers, medical practitioners, researchers and others. We found that,

"there exists a serious disease, which causes much suffering for patients, which may be severe and incapacitating and which causes a multitude of symptoms".

We were concerned at the lack of interest shown in the UK in the very large number of peer-reviewed and published papers by researchers from other countries which demonstrated the organic nature of the illness. Instead, there has been a consistent bias towards the psychosocial/behavioural model of the illness promoted by Professor Simon Wessely and his colleagues. We noted that, while more than £11 million had been spent on psychosocial research in recent years, no funding at all had been awarded to at least 10 proposals for biomedical research. The recommendations of the Chief Medical Officer in his report on this illness published three years ago seem to have been totally ignored by the MRC. As well as calling for much more research into the biomedical aspects of the illness, we recommended,

"that this condition be recognised as one which requires an approach as important as heart disease or cancer".

My main reason for adding this section to my speech today is to draw the Minister's attention to our core findings, but I must also express my concern about a series of documents published on 4 October this year under the heading Occupational Aspects of the Management of CFS: A National Guideline. The details in these documents are truly worrying. In essence, they pre-empt the NICE guidelines, currently being finalised. They emphasise the psychosocial model and appear to imply that patients or employees should not be allowed to lie in bed at home or to avoid activity and should be persuaded to undertake a programme of graded exercise (GET) and cognitive behaviour therapy (CBT). There seems to be no differentiation between individuals who have symptoms of chronic fatigue associated with clinical depression—the noble Lord, Lord Layard, mentioned that—for whom these may be a solution, and those who have CFS/ME as described by the World Health Organisation's ICD-10, G93.3, which the Minister will recognise.

I know that at least four individuals whose writ appears to run through the Department for Work and Pensions and the MoD as well as the Department of Health, and who seem to have a consistent interest in preventing the acceptance of anything but the "it's all in your mind" model, have been involved in the production of the publications. May I ask the Minister how many doctors or other advisers who accept CFS/ME as a biomedical illness were involved, how much did the exercise cost, and what will be the standing of the documents once the NICE guidelines have been published?

Photo of Lord Morris of Handsworth Lord Morris of Handsworth Labour 1:49 pm, 7th December 2006

My Lords, in speaking in the gap I declare an interest which I share with thousands—indeed the majority—of citizens in our country. I shall first say a few words about funding and performance and then share my experience as a National Health Service consumer. I record what I am sure is the overwhelming appreciation of your Lordships' House for the thousands of dedicated workers, staff and others, in the National Health Service who deliver excellent healthcare literally night and day.

Without any apology, I start from the position that the National Health Service represents a contract between the state and citizens, with universal contributions paid by those in work in return for universal care that is free at the point of use. It is important to ask how the Government have performed on issues such as funding and performance. We are told that investment has been doubled, and is even to be trebled by 2010, equalling the European average. Staff numbers have increased, waiting times have been reduced, there are fewer cancellations of operations, and cases of suspected cancer are seen within two weeks of referral. Those are real achievements that must be recognised—but at what price? The price has been greater centralisation, loss of local democratic accountability and, as we heard, a severe reduction in the night service available from GPs. We are also leaving a capital debt burden to the next generation.

In personal terms, from my experience as a consumer, I see the NHS as a success story. As a traditionalist, I recognise the programme of reform that is being implemented in making the National Health Service much more user-friendly. My own GP practice is a responsive NHS unit that understands the pressures of the 24-hour society. In my practice, a telephone call at 8 am gets you a return telephone consultation between 9 and 10 am. I am able to discuss my medical needs, including medication, on the telephone. There are also NHS walk-in centres and NHS Direct, which add value to the National Health Service.

With that service from my practice, the phrase, "I want my medical needs delivered at a time of my choice and at a place of my choice" is no longer reserved for the privileged few but is a reality for many. The NHS is often referred to as the "jewel in the crown". It is a crown that I defend not by choice but as a duty.

Photo of Baroness Neuberger Baroness Neuberger Spokesperson in the Lords, Health 1:52 pm, 7th December 2006

My Lords, I, too, thank the noble Lord, Lord Colwyn, for introducing the debate today. Like many other noble Lords in the Chamber, I would like to address an enormous number of issues, but I will reduce my remarks to make my speech shorter in a very long debate. People will be very pleased to hear that. I have to declare some interests. I am an honorary fellow of the Royal College of Physicians, the Royal College of General Practitioners and the Royal College of Psychiatrists, an honorary fellow of the Faculty of Public Health, and an adviser to the Sainsbury Centre for Mental Health.

I really want to address the emphasis that the Prime Minister and others have put on the necessity of keeping up the pace of change—of reform—in the NHS, even while accepting that, to some extent, the Department of Health in particular and the Government in general have not made a very good fist of getting people to understand why that is so vital. In the Queen's Speech we heard the bald statement about keeping on with the reform of the NHS, without any clear statement of what that direction might be. Now two NHS tsars, Dr Roger Boyle and Professor Sir George Alberti, tell us that emergency provision and some cardiac services are unsafe as configured at present and that they need to be centralised for greater expertise and safety reasons. They are very likely right, yet at a time when deficits are hurting and much of the public, let alone front-line NHS staff, believe that this has more to do with money than with better services, it is rather difficult to make the case.

As the noble Lord, Lord Colwyn, said at the beginning, with accident and emergency and maternity services being taken further away, people do not trust the Government with our much-loved NHS. I say to the noble Lord, Lord Graham—who rather took the economist Rudolf Klein's view that the NHS is perhaps a church rather than a garage, though the right reverend Prelate and I might disagree with that—that people love and respect the NHS, but that does not mean that we always think it has got it right. The noble Lord, Lord Parekh, pointed out that perhaps the NHS needed to listen harder to some of its patients when removing services from their immediate locality.

The noble Baroness, Lady Masham, raised the issue of getting help in the immediate locality when you need it in the middle of the night. My noble friend Lord Rodgers of Quarry Bank raised the very important issue of stroke services, not for the first time. We know that stroke is a huge problem. Despite the Government's assurances and reports going back over 10 years—when I first arrived as chief executive of the King's Fund in 1997 there was already an NAO/King's Fund report on what was needed in stroke services—despite everything we have said and guidance for treatment of older people and people with stroke, such an approach has still not really been implemented. Yet it is an agreed, evidence-based approach. When does the Minister think that it will be well integrated into the service?

Equally, the noble Lord, Lord Layard, raised the issue, as he has powerfully done for some time now, of evidence-based psychological therapy. GPs want it and the evidence supports it, as does the Royal College of Psychiatrists, yet many people with quite severe mental illnesses get therapy on the cheap. If you go to the United States, you can see services in cities such as Philadelphia that are provided free to homeless people. They would not tolerate the level of service in psychological therapies that we are still offering our patients. The noble Lord, Lord Layard, is quite right to say that in such mental health services everyone who suffers should be treated as we would like to be treated. We should get rid of the poor-law mentality.

Although I have to declare an interest because of the Sainsbury centre, I would like to commend what the noble Baroness, Lady Murphy, said about deficits. There are major deficits, and the budgets of two-thirds of mental health trusts have been raided, although they kept within budget, to plug the deficits in the acute sector. This is occurring at a time when we are concerned about the kind of services provided in mental health.

As a former NHS trust chairman, one of my real concerns is that the pace of reform is such that people do not have time to let change bed in before there is yet more change. We all accept that there is much more money in the system, yet we have record deficits. We all accept that the architecture brought in by the Government—NICE and the Healthcare Commission—is broadly sensible and to be welcomed, yet there are questions of detail around NICE. With nurses unemployed, older patients malnourished in our hospitals because nurses say they do not have time to feed them, and doctors complaining of the changes in medical education and what happens at the end of medical training, and with serious concerns about privacy in the data system which is being rolled out, as the noble Earl, Lord Northesk, pointed out, it seems that there is plenty to sort out. When it comes to dignity campaigns and dignity nurses in every hospital for older people, one can only say that perhaps it is a good thing that that rather crazy initiative has been quietly parked. It cannot be one nurse's responsibility to give dignity to older patients; it has to be everyone's concern.

The founders of the NHS recognised the importance of underpinning the delivery of health services with a commitment to research and education, and successive Secretaries of State for Health have reaffirmed that commitment. The tripartite mission of research, education and service delivery has put our university hospitals at the forefront of innovative and high-quality patient care, even though the money at their disposal is as nothing compared with what they might have if they were in the United States. The £3 billion invested annually by the Government and medical research charities achieves huge success, as the noble Lord, Lord Crisp, said, when compared with the £2 billion invested simply in the greater Boston area of the United States. British doctors and scientists are exceptionally creative and effective, which we have to put down to the high quality of education and training they received early in their career. Yet current initiatives are undoubtedly endangering this precious base. Some 25,000 students now enter our universities to study nursing, 8,000 to study medicine and a further 1,000 to study dentistry. That is hugely better than 10 years ago but essential due to our ageing workforce.

The funds to support education and training of the healthcare workforce have traditionally been ring-fenced, as others have said. The noble Lord, Lord Walton, made a very strong case on the point. This year, for the first time, the funds have been delegated to the strategic health authorities to be used locally as deemed fit. Although it is hardly surprising that the greatest cuts in those education and training budgets are being experienced in SHAs with the greatest deficits—as the noble Baroness, Lady Murphy, said—it is hugely short-sighted. It seems illogical, to put it mildly, that the Government are introducing the new system of payment by results, with their national tariff for NHS procedures, but fail to have a national tariff for education and training.

Cuts in education and training are being imposed without consultation around the country. There is no monitoring of SHAs' performance on education and the quality is undoubtedly suffering. That does not make any more sense than to have newly qualified nurses unemployed and specialist nurse roles threatened or asked to be generalist, yet to have a considerable number of agency staff working in the system. Transparency is a mantra often repeated by the Government, yet there is no transparency in the SHAs and education budgets. Surely, given the original investment, a national framework needs to be agreed so that we can protect the next generation of healthcare workers.

I want to move on to what the right reverend Prelate the Bishop of Worcester said about the financial regime, which is so draconian that all round us we are seeing eccentric cuts including, as he said, to chaplains in his local patch and threats to chaplains in other areas of the NHS. There seems to be no explanation for those cuts and no one seems to know how many are the result of moneys owed to PFI companies. A steady stream of money is going to those companies, as the noble Lord, Lord Selsdon, said. It looks like a debt, as the right reverend Prelate said, and it feels like a debt. Is it a debt? Is the noble Lord, Lord James of Blackheath, right in asking for clarity in the figures?

The right reverend Prelate was concerned also about the heart of the service. Noble Lords on all sides of the House love and respect the NHS. I very much hope that the Minister will respond to some of the issues raised by all noble Lords that demonstrate our concerns about the heart of the service. If the heart of the service does not care for the most vulnerable, and people do not think about the values of the service—as happened five years ago in the NHS Plan, which has sadly been somewhat abandoned—then the staff will not feel comfortable and patients will feel even more uncomfortable. I hope that the Minister can say something about that.

Photo of Earl Howe Earl Howe Shadow Minister, Health 2:03 pm, 7th December 2006

My Lords, my noble friend Lord Colwyn is liable to be asked rather often from now on to lead our health debates in this Chamber because his speech today was quite masterly. When it comes to dentistry, we always expect him to lead the way for us, but we have been reminded of how well he can do so across the full canvas of current health issues. I congratulate him most warmly.

As we look at the NHS today we see a seemingly inexplicable paradox: more money going in than ever before, yet services under very intense financial pressure. As my noble friend said so clearly, that pressure is manifesting itself in visible cuts, and the cuts that we are seeing are not in the least peripheral. They are in core areas. Education and training budgets are being raided to offset deficits in service provision. Nurse posts are being frozen or cut, not because of staffing requirements but because cash cannot be found. Almost half of newly qualified nurses have not found jobs this year. In physiotherapy, the percentage is much higher.

Maternity units, both midwife-led and consultant-led, are being closed down or are under threat of closure. This is happening not on the basis of service effectiveness or what patients want but largely because of budget cuts. So much for patient choice. In the very topical area of mental health, more than half of mental health trusts, as we have heard, have seen money diverted away to prop up the local NHS economy, with the result that in many areas wards are being closed or are under threat of closure. The Community Hospitals Association says that 81 community hospitals are under threat of cuts or closure. Elsewhere in the community, far from there being more midwives, health visitors and district nurses, the numbers have actually fallen.

The latest issue in the headlines is A&E departments, 29 of which are under threat of closure. We all understand that service configurations cannot be set permanently in aspic, but instead of being up-front about the real reasons for making changes, the Government are talking about improved patient care. In many if not most cases, there are two real reasons: the European working time directive and shortage of money. Matters of that kind are of absolutely critical importance for saving lives and should be decided mainly on a balance of safety and access. But the actual evidence base for what constitutes the right balance is nowhere to be seen. We are being fed a bogus rationale, and that is deplorable.

The Government are fond of saying that, with all the extra money being channelled into the health service, budgetary pressures are simply the result of poor decisions at local level. I do not buy that line, and perhaps I may tell the Minister why. The reasons for the present financial pressures are many, but there are three that have nothing whatever to do with local decision-making and everything to do with decisions by Ministers. They are: the deliberate top-slicing of PCT budgets by Whitehall, which effectively removes much of the growth money from PCTs; NHS reorganisation; and woefully disjointed implementation of government policy.

The top-slicing of budgets brings us back to old-fashioned brokerage, only this time it is being applied indiscriminately. Where all this money is going to be applied, we shall no doubt hear in due course. But an equally big, if not bigger, cause of difficulty is the adverse effect of NHS reorganisation. Frankly, I have lost track of how many reorganisations of the NHS there have been since Labour came to office, but Ministers' passion for restructuring the health service has been hugely expensive. This year, the redundancy bill alone will be anything up to £400 million. It has also been expensive in another sense in that it has engendered a climate of seemingly continual upheaval and change. The main casualty of that has been something supremely precious: staff morale. One PCT chair giving evidence in another place to the Health Select Committee inquiry into primary care trusts said that some of the staff in his area have had five different employer names on their payslips in less than 10 years. The combination of uncertainty, constant upheaval and poorly managed announcements has made committed PCT staff feel unsettled and undervalued.

Nowhere, perhaps, has reorganisation been more disruptive than in public health. The number of full-time equivalent doctors in public health has gone down by 19 per cent over the past few years. Yet this year, four out of 13 medical deanery regions have cancelled their spending on public health training altogether. The Chief Medical Officer has spoken of,

"a consistent story of poor morale, declining numbers and inadequate recruitment and budgets being raided to solve financial deficits in the acute sector".

The reorganisation of PCTs has halved the number of posts for directors of public health. A recent survey showed that one in three public health doctors is considering leaving the field because they are worried about the future and demoralised. The danger is that we are losing the very people whom we need to provide leadership and experience in this vital area of long-term preventive work. We cannot afford that.

The third factor that I wish to raise is the disjointed implementation of government policy. The GP contract, though beneficial in making general practice more attractive to doctors, left it to PCTs to ensure adequate out-of-hours cover. That abdication in the contract, we now learn, has cost no less than £346 million a year, more than three times what the department budgeted for. It is no wonder that PCTs are struggling to find that sort of money; but it is hardly their fault. Hospitals, locked into PFI contracts, have found that, under payment by results, the goalposts have been moved: their income is now more volatile and the level of the tariff is not realistic in relation to their running costs. It is a truly classic example of one piece of government policy cutting across another. Then there is the unco-ordinated way in which market mechanisms have been introduced to the NHS, and especially the destabilising effect of payment by results.

Payment by results was always going to be an extraordinarily difficult system to embed into the health service. We could have guessed that simply from the problems experienced in other countries which have tried it. But, instead of learning from the experience of other countries, we have reinvented our own version of the wheel and have chosen to do it in a rather crude way. As an indicator of costs, the tariff is a very broad-brush sort of measure. It is essentially an average of a wide range of treatments and case-mixes, resulting in considerable cross-subsidy between different procedures. That may be all right where hospital providers have security of income, but it is highly vulnerable to competitive intervention from providers who choose to focus on routine, high-volume cases or who can deliver treatment at a lower cost than the tariff assumes. We see exactly that kind of destabilising competition going on now.

One of the key features of payment by results is that it is a powerful instrument for incentivising activity. It is literally a market-making tool. So, if you are going to let it loose, you need to apply it within an environment where costs are calculated with some precision, where there are relatively strong purchasers and where there is effective competition among providers.

However, that is not what the NHS has, and, in many cases, the result is severe financial stress at PCT level. Payment by results has not been introduced in parallel with an effective means of managing demand. That is not the NHS's fault; it is the result of poor planning at the centre. One day, practice-based commissioning may provide the necessary counterweight on the purchaser side, but it has not been rolled out properly or soon enough.

The NHS continues to provide dedicated and often very fine care and treatment, despite its financial stresses, but we really need to see those stresses in their right context. The Government are entitled to take credit for the improvements which there have undoubtedly been, but a little frankness and contrition occasionally would not go amiss.

Photo of Lord Warner Lord Warner Minister of State (NHS Reform), Department of Health, Minister of State (Department of Health) (NHS Reform) 2:12 pm, 7th December 2006

My Lords, this has been a wide-ranging debate. I shall not be able to respond to all the points but I guarantee to write to people because some of those points were detailed and require, and deserve, a longer explanation than I have time for.

I am grateful to the noble Lord, Lord Colwyn, for this opportunity to discuss the current situation in the NHS because it provides me with an opportunity to remind noble Lords about the real situation and achievements in the NHS under this Government. It also gives me an opportunity to talk a little about our vision of the future and to counter some of the wilder accusations that are currently circulating, a few of which we have heard today.

I reassure the noble Lord, Lord Selsdon, that I shall not be giving him a story of perpetual sunshine, which his political leader in the other place occasionally indulges in; and I assure him and the noble Earl, Lord Howe, that I accept that sometimes it rains in the NHS. But—and it is a "but"—I am pleased to have the opportunity to remind people about the past. I believe that one of the best predictors of future behaviour is past behaviour. I do not want to dwell on this too long but I have to remind people, painful though it may be, of the legacy that we inherited, and my noble friend Lord Graham has already reminded us of the situation before the NHS came into being.

When this Government came to office in 1997, the NHS had a largely Victorian infrastructure. According to the King's Fund, in 1997, the average age of NHS buildings was older than the NHS itself. There were staff shortages: 37 per cent fewer doctors; 27 per cent fewer nurses; 36 per cent fewer allied health professionals; and 17 per cent fewer GPs; and the previous Government did not even bother to count separately healthcare scientists. Two dental schools had been closed in 1992 in London and Edinburgh, causing a loss of 80 training places. There was a history of staged pay awards: eight for doctors and five for nurses and midwives. Perhaps most interestingly—this will be of particular interest to the noble Lord, Lord James, in his thirst for knowledge about financial deficits—the NHS financial deficit in 1996-97 was £459 million, which was 1.5 per cent of the total NHS allocation, compared with 0.7 per cent of the total NHS allocation for the deficit in 2005-06. I do not want to dwell too much on this but that is the context that we inherited, and it has an impact on the current situation.

I accept that there is still more to do if we are to have a 21st-century healthcare system. But, since 1997, we have seen far-reaching improvements, which many people have acknowledged today. There are now 404,000 extra staff: 85,000 more nurses; 122,000 more doctors; 61,000 more allied health professionals; and over 16,000 more radiographers and physiotherapists. Those are large increases by any stretch of the imagination. There are nearly 4,700 more GPs than there were in the past. Part of the reason why we have more GPs and other staff is that we pay them better, and I shall come to that a little later.

We are investing in more training places to secure future staffing levels: 10,600 more medical students have entered training since 1997; a major expansion of dental training is under way; and over 10,000 more nurses and midwives are being trained than in 1996-97. I accept that the money being spent on training in the current year has plateaued off, but it is doing so following huge growth, and the money that was allocated to SHAs in the current year for SIFT and other payments is roughly the same amount as was issued in the previous year. Of course, we have given SHAs authority to take account of local priorities in spending the money but, listening to some of the discussions, one would not have recognised the level of the increase in the money for education and training that has been put into the system.

We have literally hundreds more hospitals, GP surgeries and health centres, thanks in part to the private finance initiative; and there is no evidence that the PFI initiative has caused a huge number of deficits. It is worth remembering that all the trusts that entered into a PFI agreement were asked to test against rigorous guidelines the affordability of the project that they wanted to go forward with. All those projects were subject, as are LIFT and other projects, to Her Majesty's Treasury's value-for-money scrutiny. So we have a rigorous system in place.

We have improved services and access to those services. We have cut waiting lists—260,000 fewer people are waiting compared with six years ago; we have improved access to A&E departments and GPs; and there are improving mortality rates. For example, deaths from cancer in the under-75s fell by nearly 16 per cent between 1997 and 2004. That is not just a statistic; it is 50,000 lives saved—50,000 people are alive when they would not otherwise have been. And we are on track to reduce deaths from heart disease by 40 per cent—or 150,000 lives—by 2010.

We have begun the process of implementing a national programme for IT. It is simply not true, as the noble Earl, Lord Northesk, suggested, that we have had little progress to date. I cannot go through all of it but, for example, more than 90 million digital images are now stored, with people using the picture archive and communication system packs. We are getting close to the point where 50 per cent of patients in the NHS will have their images on that picture-archiving system, instead of X-ray films. I shall give the noble Lord all the details and will circulate them to all other noble Lords.

My noble friend Lord Layard rightly paid tribute to the improvements that have taken place in mental health. There have been huge improvements, and I pay tribute to the work that he has done on talking therapies. We certainly want to continue working closely with him on them. Since we published the National Service Framework for Mental Health in 1999, planned spending on mental health has gone up by more than 25 per cent in real terms—nearly £1 billion a year.

Let me reassure my noble friend that there has been a huge shift in services from in-patient services to the community, with new roles for staff and new, more individual services for service users. For example, in 2005-06, almost 84,000 home treatment episodes took place for people who would otherwise have required in-patient admission. We have expanded community services for people with mental illness. One of the reasons why we need new mental health legislation is because the 1983 Act is out of date.

All these improvements have been delivered thanks to the dedication and commitment of 1.3 million NHS staff as well as the Government's record levels of investment. I share the views of other noble Lords that these improvements are down to those staff and their hard work day in, day out. But their job is made easier by the fact that there are a lot more of them to do it than there were 10 years ago.

Of course, everything is not perfect, and probably never will be. But we have to consider what patients who experience the NHS have been telling us. They tell a different story from some of the stuff in the media. According to the most recent findings of the Healthcare Commission's—not the Government's—national patient survey programme, 92 per cent of adult in-patients rated their care as good or better, as did 94 per cent of adult out-patients and 88 per cent of those who had experienced A&E. That survey was carried out this year. In primary care, 97 per cent of patients said that the main reason they had for visiting their practice was dealt with to their satisfaction. When asked about their experiences, NHS users report a totally different NHS from that which we read about day in, day out, in many of our media outlets.

I am proud of what the NHS has already achieved in the face of fundamental and, sometimes, painful change. I acknowledge that change is difficult; it is tough; it is hard going. But more is inevitable, not just because the Government are dreaming it up, but because we have to make continuing improvements in health and social care.

The noble Lord, Lord Crisp, drew attention to the experience overseas. All advanced countries with healthcare and social care systems experience the challenges that we are experiencing. There is no escaping those challenges, and I shall mention three in particular. I can understand why the right reverend Prelate and others want us to walk more slowly. I suggest that the challenges that I shall describe make it difficult for us to do so.

First, I refer to demographics. Our population is getting older and more of us are living with illness. By 2025 there will be two-thirds more over-85s. More and more people are living with long-term conditions, and more and more profoundly disabled babies are living to adulthood. This means a massive increase in demand on health and social services.

Our 21st-century lifestyles do not always help. By 2010 we expect almost 13 million adults to be clinically obese, and we are already seeing the associated rise in strokes, heart attacks and type 2 diabetes. The second challenge is that we are experiencing a revolution in medical technology. The noble Lord, Lord Crisp, rightly drew attention to the good track record in this country in biomedical science. Every week, new drugs and treatments are being developed. In a few years' time, doctors will be able to use drugs that are tailored to the unique DNA of an individual patient. It is quite clear from a casual reading of the media that people want those drugs made available to them, especially when they deal with a life-threatening situation. These advances are, of course, to be celebrated. However, there is no escaping the impact they will have on the cost of treatment.

Finally, there is the inescapable fact that the expectations of our fellow citizens continue to rise—as do our own—as more opportunities to help people present themselves. Waiting times are shorter, but they are not short enough. People also want the NHS to provide them with the same level of control, choice and convenience that they expect from other services. We all expect that as individuals, so why should not everybody else? That presents a challenge. It is also a challenge to ensure that the groups to which my noble friend Lady Howells rightly referred share in those benefits. We must tackle health inequalities even more vigorously.

People want to be treated closer to home; they have made that clear. They want less invasive procedures. If most of us are confronted with a less invasive therapy or surgery, we will take the less invasive procedure. But that has consequences: consequences for the staff providing the treatment, consequences for the places where the treatment is provided and consequences for at least transitional costs. The Institute for Healthcare Improvement report published today makes it clear that providing care closer to home is undoubtedly possible. We want to make sure that the opportunities to do this are grasped. We want a health service, not just a sickness service, in this country. We want to rebalance the system towards ill health prevention and good health promotion. Our future-oriented White Paper, Our Health, Our Care, Our Say, published in January, set out a clear direction of travel. We are already making good progress in many areas. I do not have time to dwell on all of them, but something for which the Government deserve great credit is the Health Act, which is now in place, and we are committed to implementing smoke-free legislation in the summer of next year. Tobacco does kill, and we have taken action to reduce the impact of that on a wide range of people, including some of the poorest in our society.

Sexual health is a challenge, but it is one of the top six priorities for the NHS in 2006. That is why we are investing more money in modernising sexual health clinics and services. We will be debating some of these issues in more detail next week, so I shall not spend too much time on them now.

A number of noble Lords talked about some of the issues relating to reconfiguration of services. Technological advances pose a challenge, but they represent a golden opportunity to make services safer and produce much better outcomes for patients. They often represent an opportunity to improve efficiency. I recognise that the transition for that, to which a number of noble Lords referred, causes difficulties for those who have to change the way in which they work, or where they work. It also means reskilling programmes and often means a transition set of costs. No Government will find it easy to make cashable savings in acute hospitals as service configurations change. This is a tough challenge for any Government in any healthcare system.

Monday of this week saw the launch of the personal reports of Professor Sir George Alberti and Professor Roger Boyle, the national clinical directors respectively for emergency access and heart disease. Both of them are eminent clinicians with the best interests of patients paramount in their thinking.

Roger Boyle, in his Mending Hearts and Brains—a graphic title—showed us the evidence that it is safer to bypass the nearest local hospitals to make sure that a patient gets specialist treatment in the right setting from doctors and nurses with the right skills to save lives. A patient taken directly to a specialist angioplasty centre is likely to recover from a heart attack or stroke more quickly and without continuing debilitating illness. The way forward for many of the concerns about stroke that the noble Lord, Lord Rodgers of Quarry Bank, rightly drew attention to, is described by Roger Boyle in that document. I recognise that the glass needs to be fuller and that we must work on stroke services.

When the NHS reorganises, it does so primarily for the benefit of patients. Despite what our critics might say, reconfiguration is about providing better, safer and more convenient care. As the noble Baroness, Lady Murphy, said, transformation is sometimes accelerated by the need to look at how the money is spent. In producing their personal reports, the national clinical directors have highlighted how more patients are already being treated outside hospital. That trend will undoubtedly continue.

Your Lordships will be pleased to know that I shall not dwell on how much we have spent on the NHS, but expenditure improvements have been huge. It is not unreasonable to expect that, within that rising growth, there should be good financial management of those resources. There is no particular reason why some of that money could not have been better spent. We must concentrate on those parts of the NHS with serious financial deficits, but we must keep that in proportion. At the end of quarter 2 of 2006-07, 50 per cent of the NHS gross deficit—not the net deficit—is concentrated in only 6 per cent of organisations.

I recognise that some parts of the NHS have reacted to years of staff shortages and underfunding by recruiting faster than was perhaps necessary. For example, we set several targets for increasing the number of nurses which, taken cumulatively, would have given a staffing level of 385,000 by 2008. This level of growth was achieved in 2003. We now understand that we are seeing a degree of accelerated recruitment. Of course, that will cause some trusts difficulty. Overall, however, I would sooner be in that position than the one the NHS faced in 1997.

I do not have time to continue far along this path, but the noble Lord, Lord James, was concerned about the absence of data. I commend to him the annual report of the Healthcare Commission on the state of the NHS and the performance of individual trusts, produced each year, which gives a lot of information about financial management and quality in those trusts. I also commend the six-monthly reports of the NHS Chief Executive—begun under the noble Lord, Lord Crisp—which give a wealth of data on how well the NHS is running. They give a lot more detail on how things are improving than the report which the noble Lord served up to the previous leader of the Conservative Party for the last election.

In conclusion, whichever way you look at it, the net outcome of our investment in the NHS and the changes already made are a good deal for patients, providing a good base for the future. We have preserved the founding principles of the NHS: the values of a publicly funded service, free to all, equally, at the point of need. We have safeguarded that for future generations.

Photo of Lord Colwyn Lord Colwyn Conservative 2:35 pm, 7th December 2006

My Lords, only a few seconds remain in this short debate. I thank all noble Lords who have taken part and recognise that their contributions have demonstrated a wide range of expertise and experience.

The Minister did not mention the dental treadmill, which is of particular importance to me. I hope that he will note the plea of the right reverend Prelate the Bishop of Worcester for targets for walking slowly and gentle, caring involvement. Perhaps the right reverend Prelate would consider joining the dental negotiating body for targets and recognition; that sort of advice is exactly what is needed to remove the treadmill and encourage dentists to talk to their patients without having to earn points for invasive treatment.

The NHS is a wide-ranging subject. I know it will be debated on many occasions in future. In the mean time, I beg leave to withdraw the Motion for Papers.

Motion for Papers, by leave, withdrawn.