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Part of the debate – in the House of Lords at 12:34 pm on 7th December 2006.

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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.