HL Deb 22 February 1989 vol 504 cc658-749

3.17 p.m.

Lord Hunter of Newington rose to call attention to the Government White Paper Working for Patients (Cmnd. 555); and to move for Papers.

The noble Lord said: My Lords, if you think of the beginning you should perhaps think of John Pater's book The Making of the NHS, particularly as he deals in great detail with the aspects of the health service that are concerned with this debate. He devoted 40 years of work in the Department of Health. No one will ever know just how great his contributions were. His book was published by the King's Fund. The chairman at the time is here and he will be speaking; namely, the noble Lord, Lord Hayter.

Chapter 7 of Mr. Pater's book is entitled "The End of the Beginning". Forty years later we are dealing with the continuation of the same. There is no sign whatever that any end is in sight. What is the background of importance and relevance to today? There were two beginnings. One was the Lloyd George Act of 1911 which launched general practitioners on the independent contractor path. The second was the experience during the war of the Emergency Medical Service. This completely demolished the traditional barriers between the voluntary hospitals and the local authority ones. It was obvious that this was a success and of benefit to both. It did not go unnoticed by Pater and his colleagues in the Department of Health.

In 1948, with the introduction of the health service, the centrepiece was the hospitals. General practitioner services and local authority medical services were unchanged to begin with. In the mid-1960s there were events of importance to this debate. One was the general practitioners' charter, which was most successful in recruiting doctors to family practice and firmly establishing this as a gateway to the health service. Another was the inquiry of the noble Lord, Lord Seebohm, into the social services.

The Department of Health and Social Security was founded in 1968 and lasted for 20 years. One thing that happened subsequently in relation to community medicine and preventive medicine was the disappearance of the medical officer of health in 1973. Many have lamented his passing. But at about that time also the Health and Safety at Work Act was passed, setting up the Health and Safety Commission, one of the most successful ventures in public health. A little later the policy was adopted by the noble Lord, Lord Jenkin of Roding, when he was Secretary of State, to embark on the return of the mentally sick and handicapped to the community. Sadly, little preparation seems to have been made to receive them.

The increasing number of old people has already added to the community's burden as well as to the burden of the NHS. Much of the problem concerns accommodation and caring rather than the medical services. One acute problem is at the interface of local government. The other, and the main one, is escalating costs and doctors' freedom to prescribe what they wish. During the 1980s public health and preventive medicine have become increasingly important, particularly in the field of AIDS, hepatitis B, the inoculation of children and, need one mention, food contamination. An important point is that demand for preventive medicine has enormously increased. This includes screening for cancer in women. Incidentally, the Abortion Act 1967 has substantially added to the burden on the National Health Service hospitals for operating theatre time. Only in the past few days the Audit Commission report entitled The Prevention of Heart Disease revealed a woeful record.

I mentioned some of the background briefly because many of these points are not considered in Working for Patients. The basic thinking, io me at least, seems very similar to that of 1948 and the arguments used then, arguments concerned with the immediate diagnosis and treatment measures by general practitioners and hospitals. And these, because of the nature of the report, are the focus of the debate. It is important to get this right and to remember that the acute services in general practice and in hospitals which we shall be discussing, and the management of those services are only part of the whole picture.

In Working for Patients dentistry is not mentioned, though dentistry is facing a crisis at this time. Even more important, medical research is barely mentioned; nor is research and development in this enormous business in spite of the advice tendered by the Select Committee on Science and Technology. We had hoped for an answer to these proposals during the debate. I shall say a word about central management later, but I cannot refrain from mentioning the report of the committee which I chaired in 1972 on medical managers.

The Conservative Government of the day did nothing about managers and introduced the idea of consensus management, one of the great time-wasters. Some years ago, as the House will know, the Government changed their mind and went for management executives. Working for Patients greatly strengthens the role and authority of managers, but because of the proposals about audit, which I now believe are widely accepted within the medical profession, the whole question of the status of medical managers must be urgently addressed. Incidentally, will the Government give an assurance tonight that audit will be adequately funded? The Lothian experiment in Scotland showed that up to 10 per cent. of consultant time may be required to do it properly.

I have no direct knowledge of the function of family practitioner committees but I am interested to see once again that their position and connections have changed. A few years ago the Government decided to make family practitioner committees directly responsible to the Secretary of State. Now they are again to have connections with the district health authorities, with the future possibility of being united with those authorities. They will have direct connections with the regional health authorities. Suggestions are made that their membership should be altered. There is no doubt that this area needs examination and discussion with the people concerned.

One must consider the size of general practices. Very many people prefer small practices of two to four doctors because they are accustomed to a highly personal service. If change is to take place the matter will not be resolved by the doctor making contracts with hospitals at the right price. It will be resolved by the maximum number of investigations being carried out in the large practices and the proper business arrangements being made to ensure that they are less costly than hospital investigations.

During the proceedings on the Health and Medicines Bill we learnt a great deal about the cost of procedures carried out inside and outside hospitals. We learnt that a routine eye test in a hospital costs twice as much as the procedure carried out in an optician's premises by a medically qualified doctor. The White Paper on primary care and public health made considerable reference to the increased use of the professions allied to medicine. In particular, it mentioned the value of pharmacists in giving a whole range of practical advice. In the past six months I have been thinking a great deal about how one can use the professions outside the hospitals. They are highly qualified professional people who seem at times not to be fully used, and to do so may well be cheaper. If one thinks in terms of Working for Patients and about the proposals for the development of large practices, one wonders whether a much more radical look should be taken at practices.

In 1920 no less, the Interim Report of the Consultative Council on Medical and Allied Services suggested that the future of the embryo health service involved the development of what were called "secondary care centres", where a whole range of facilities intimately concerned with the diagnosis and treatment of patients and specialist support would be available to general practitioners. Could this be the new self-governing community unit?

The opportunity exists at the present time to get family practice on an evolutionary path. Therefore one wonders whether some of the first 50 or so of the large practices which the Government anticipate will be having their own budgets should be the subject of an important series of experiments which could consider not only the patients, though their welfare is of prime importance, but also something which should appeal to this Government; namely what equipment and facilities, including some of the new radiological equipment and specialised staff, should be made available in a practice of 10,000, 12,000 or 20,000 patients.

Such is the nature of technology and the development of new instruments that it may be possible in a decade to have a diagnosis of cancer confirmed or refuted within a matter of hours, and not the days or weeks which sometimes elapse at the present time. The patient will really respond to such an improved service as will the allied professions. These proposals are of fundamental importance. The Royal College of General Practitioners in its studies over the past several years has laid the ground work for this kind of development.

No one is suggesting that there should be an interference with the clinical responsibility or decisions of doctors, but a whole range of new procedures do not need to be carried out by doctors in the first instance. The doctor must have the results, he must see the patient, he must consider the patient's illness and the kind of people he and his family are, and then decide on treatment. Those responsibilities cannot be delegated. But on the other hand many things, including health education, though they may be done by doctors when it is relevant, do not need to be done by doctors all the time when able people with specialist training could do them effectively. This is true also of specialised investigations. In fact, a similar position exists in hospitals where a range of procedures can and should be carried out by nurses. For example, a doctor should not be woken at night, something of which the noble Lord, Lord Rea, will approve, to adjust the intravenous drip. When I was a house physician the best person to carry out those practical procedures was the ward sister.

I turn now to the proposals about hospitals. It is proposed that the NHS Hospital Trusts should be given a range of powers and freedoms which are not and will not be available to health authorities generally. Does that include the teaching centres? At paragraph 3.10 it says: Greater freedom will stimulate greater enterprise and commitment, which will in turn improve services for patients". Is that true? Has it been shown to be so? Further, what authority, if any, has the district health authority in the matter?

One aspect which must be studied is what has been called the "Guy's Hospital proposals". Here one should be cautious. The London teaching hospitals have been the subject of 10 years of RAWP (the resource allocation working party) reductions in London, with much of the money saved being spent on the development of new medical centres in Nottingham, Leicester and Southampton. It is most important to consider whether a large district hospital in the periphery of a manufacturing city is likely to be run for the benefit of the patient in the same way as Guy's Hospital in London.

One brief paragraph in the White Paper, paragraph 4.30, refers to teaching and research and makes reassuring noises about SIFT, which is service increment for teaching. It tells us that an interdepartmental committee is looking at the now rather stony, grey area between health and education following the formation of the Universities Funding Council. However, the Government say that they are determined to ensure, that other costs associated with the training and research are also met", without putting one hospital at an unfair advantage by comparison with another. But, what does that mean? Are there to be any specialist facilities in the main teaching hospitals? Millions of pounds have been spent over the past 25 years creating teaching centres where the wards and the laboratories of the university and the hospital are intimately connected. Associated with that successful development has been the knock-for-knock principle, which is more important than SIFT. It is an agreement between two government departments not to itemise costs and that has been successfully applied to the grey areas. In fact, I believe that that agreement made it possible. However, is that all to be radically changed? If so, it could threaten successful arrangements which have been the envy of other countries.

If you enter the main teaching hospital at Stanford University in the United States, the first thing you see above the door is an enormous structure. It is the computer which divides the cost between the local authority and the university. Is that what is proposed; namely, to divide the costs between two government departments? Perhaps I may give your Lordships an example. A patient is admitted to hospital and is seen by a consultant who is a university employee. The registrar is employed at the hospital but specialised investigations are done by one university research team using equipment that neither they, nor the health service, have paid for, but which was provided by the Cancer Research Fund. I ask, who pays? There is no mention in the document that the main centres for clinical research are in the teaching hospitals and medical schools. Indeed, paragraph 4.11 of working paper 2 states: Contract funding is likely to create pressure for research funds and clinical support responsibilities to be separately identified and funded". I wonder what the cost of that will be if this is the true situation. We look forward to hearing the Government's reply in that regard.

The working papers raise the issue of research which was largely missing from the White Paper. The new responsibilities for National Health Service managers: the move towards self-governing hospitals; medical audit; and budgeting at all levels, all add to the existing need of the National Health Service for research and development in support of patient care and public health. It is therefore essential that a research component is built into NHS management. NHS managers will of course cooperate with the MRC, the Department of Health, the medical charities and other organisations; but they should not be dependent on any of them. The National Health Service management must be directly involved in assisting, promoting and implementing research. That of course is what the Select Committee recommended and it is something about which other noble Lords will be talking a great deal.

I am glad that the Secretary of State has issued working papers setting out the proposals for discussion with interested parties. That is urgently needed before any firm views can be expressed about them. The objectives of the Government in producing their White Paper are admirable in the sense that they have the courage to recognise the necessity for getting the health service on to an evolutionary path. Moreover, they also recognise that the escalating costs must be contained so far as possible. However, the time-scale of such a development may be a good many years and unless we can get broad agreement between the principal parties involved in government, hurried changes by one party or another will damage the health service and the only sufferers will be the people of this country. The problem is a real one and the time-scale proposed by the Government in the White Paper could endanger the whole development.

I hope that the debate will be a lively one and that the Government will be receptive to suggestions and give immediate explanations to some of the more obvious anomalies to which their attention will be drawn. My Lords, I beg to move for Papers.

3.36 p.m.

The Lord Privy Seal (Lord Belstead)

My Lords, I should like to thank the noble Lord, Lord Hunter of Newington, for initiating the debate today and for the extremely interesting speech which he has just made. I believe that because it is very much in the interests of the National Health Service this debate has attracted many of your Lordships with considerable experience of medicine and of the health service.

First, I would emphasise to your Lordships that the proposals in the White Paper are founded on the Government's full commitment to the fundamental principles of the National Health Service. The service is, and will continue to be, open to all regardless of income. It will continue to be financed mainly out of general taxation. These principles have guided the health service for the past 40 years and they will continue to guide it into the next century.

Why then is there the need for a new White Paper? While the principles remain unchanged, the service itself has in many ways developed almost out of all recognition. For example, transplants and coronary by-pass surgery, not to mention such things as hip replacements, have become increasingly frequent and successful. Indeed, we have seen perinatal mortality almost halved over the last decade, so that many children are alive today who simply would not have survived a decade ago. That is a great achievement for the National Health Service and for those who work in it.

The growth of the service has accelerated sharply over the last decade. Total expenditure in the next financial year will increase from the £8 billion that it was 10 years ago to £26 billion—an increase of over 40 per cent. in real terms. We now have over 6,000 more hospital medical staff, 70,000 more nursing and midwifery staff and 1.5 million more hospital inpatients being treated annually than there were 10 years ago.

But with such a rapid rate of growth surely we need to build on the achievements of the service. So the White Paper's proposals have a simple, underlying objective; that is, to make the National Health Service even more responsive to the needs of patients.

Some of the initiatives we are taking are focused directly on the quality of the service offered to patients. We are looking to hospitals to improve the personal service they give: fuller information; more reliable appointment systems; faster notification of test results and, perhaps of the greatest importance to families, simply making patients feel more at home.

In that context there are the White Paper's proposals for the development of medical audit in both hospital and primary care services. That may have rather a "dry" sound but, by making doctors better informed about how the results of their work compare with those of other doctors, medical audit will help to ensure that the highest possible quality of medical care is provided for patients.

The noble Lord, Lord Hunter, asked me a direct question, which was: will medical audit be adequately funded? The White Paper recognises that medical audit will need a significant investment of time by doctors themselves, and adequate support, to ensure that the necessary information is available. There can be little doubt that that investment will prove its worth. Pioneering work by doctors themselves—the noble Lord mentioned the Lothian region of Scotland—is showing the way. The Government therefore aim to work closely with the medical profession in building in the important foundations that doctors have already laid.

In addressing the quality of the services provided by the NHS, the main thrust of the White Paper is to try to modernise and revitalise the organisation which is charged with delivering those services. We aim to give as much responsibility as we possibly can to those who are closest to the patient. We aim also to ensure that the available funds are channeled to where patients wish to be treated.

Under the present funding arrangements, for example, successful hospitals can find themselves caught in the so-called "efficiency trap". They become more efficient and can treat more patients; general practioners naturally want to refer patients to them; but the cost of expanding their service would break their budget because under the present system the money does not come with the patient.

So the White Paper tackles that problem by introducing far greater flexibility into the funding system. Our proposals are that in future district health authorities should place contracts for services with individual hospitals. That may mean their own hospitals, those of another health authority, a new self-governing hospital or a private hospital. Districts will decide in consultation with their general practitioners which hospitals best meet their requirements for different services. Hospitals will then be funded much more directly and quickly for the volume and quality of the services that they provide. They will also have a stronger incentive to improve the quality of care even further in order to win, and retain, a district's contracts.

I emphasise that each district will be responsible for ensuring that the health care needs of everyone living within its boundaries are properly provided for. The Government's proposals will clarify that responsibility by ensuring that district health authorities are funded for the population that they serve. Patients will need local access to many of the services which a district will purchase with the funds available to it. Those services—"core" services, to use the White Paper terminology—will be funded in a way which guarantees that local access.

The Government recognise that those funding arrangements are new, and that their implementation will involve careful and detailed work with all concerned. But we must not lose sight of the benefits of change in that case. Enabling money to move with patients will be a great incentive to both quality and efficiency.

The introduction of general practitioner practice budgets will act as a further spur in the same direction, giving patients through their general practitioners a far stronger voice than at present.

The noble Lord, Lord Hunter, went further and mentioned in some detail the possibility of general practitioner practices within the scheme hiring their own consultants, or at least that is how I understood it. I must confess that we have not considered such a radical step, but practice budgets will give general practitioners more scope for improving the services that their practices can offer to patients, both directly and by influencing the quality of hospital care.

I emphasise that there will be no disincentives on GPs to accept elderly or highly dependent patients, as I have seen suggested. The level of each budget will reflect the age and health needs of the practice's population. There will also be a cost ceiling for the treatment of any individual patient from the practice budget, after which the district health authority will meet the bill, a point which has not come through clearly in some of the discussions. Medical audit is yet another safeguard.

In short, the GP practice budget scheme offers an opportunity, not a constraint. The scheme will be voluntary. The key, again, is to allow money to go with the patient: for a defined range of treatments a GP's choice of hospital will be backed up by NHS funds. We are convinced that that in turn will bear further fruit by sharpening the responsiveness of hospitals to the benefit of all patients, not just those on the lists of participating practices.

Those new arrangements for trying to move money around to respond to the needs of patients will give fresh impetus to our efforts to curb excessive waiting, which is perhaps in the forefront of every layman's mind. The White Paper's proposals will make it easier for patients to be referred, if they wish, to where waiting times are shorter. What is more, acceptable waiting times will be one of the key criteria in setting and renewing contracts, so hospitals will need to have the issue always at the top of their agenda. At the same time the new tax relief proposals in the White Paper will not only assist many elderly patients who have paid for private practice and find that the costs become greater just when they may need elective surgery but will also reduce pressure on waiting times and so help many other patients.

Those changes are being supplemented by the creation of an additional 100 consultant posts over the next three years, to be targeted on areas with severe waiting time problems. That expansion is in addition to the 2 per cent. a year growth in consultant numbers already programmed and the additional posts already funded through the Waiting List Fund.

I hope that I have shown that the proposed changes in funding arrangements are fundamental to the White Paper's reforms and their impact on the quality of services provided for patients. But I should also like to reassure your Lordships that we have not overlooked the implications of those arrangements for two issues of particular concern to your Lordships' House mentioned by the noble Lord, Lord Hunter; namely, medical research and medical education.

The Government are firmly committed to maintaining the standard of excellence in medical research in this country. That commitment is demonstrated, for example, by the recently announced increases in funding for the Medical Research Council, from £150 million this year to £176 million in the next financial year, an increase in real terms of 12 per cent. We are now considering carefully, in the light of the White Paper, the important report of the Sub-Committee to your Lordships' Science and Technology Select Committee on priorities in medical education. The noble Lord, Lord Hunter, also talked in some detail about medical education.

I recognise the complexity and special needs of medical and dental education, and we are committed to maintaining its quality. We have, as the noble Lord knows, established a Steering Group on Medical and Dental Education, with representatives of the major bodies concerned, and that group will develop its work and make recommendations in the light of the White Paper's proposals.

Modernising and revitalising the organisation of services to patients means not only new funding but further reforms in management. In particular, we are convinced that more needs to be done to put decision-making closer to the level of the individual patient.

The White Paper's proposals will delegate authority throughout the management structure. At the centre, the new Policy Board and Management Executive will ensure that policy and operational responsibilities are clearly identified and acted upon. Regional health authorities will be concentrating more on strategy and monitoring, and at district level operational responsibility will be devolved as far as possible to the individual management units, which will work within a clearer framework of responsibility and accountability than in the past.

The White Paper makes important proposals for involving hospital consultants in the management of local services. The decisions taken by consultants are critical to the way in which the money available for the National Health Service is used. We believe that they need to be given this responsibility more clearly and explicitly; to be given the information and support they need to discharge that responsibility; and to be accountable for the consequences of their decisions.

These matters are all set in Working Paper 7. I simply say at this stage that we are determined to try to pursue these aims with vigour. We intend also to reform the distinction awards system in order to ensure that a consultant's commitment to the management and development of the service is taken properly into account in starting off on the distinction awards.

The Government's proposals to create National Health Service hospital trusts for self-governing hospitals is, I think, a natural development of our determination to delegate as much authority as possible to those who are actually responsible for delivering services to patients. So we propose hospital trusts which will be new National Health Service bodies with freedom to employ staff, determine pay and conditions of service and manage their own resources. They will derive their revenue from the contractual funding arrangements I have described and will, we think, be best placed to respond flexibly to the needs of contracting authorities and doctors. It has been said before, but I emphasise again, that self-governing hospitals will not be opting out of the National Health Service. They will be just as much a part of it as they arc now. But self-governing status for hospitals will, we believe, stimulate both the energy and the commitment of staff to respond to the needs and wishes of their patients and will attract the support and enthusiasm of local communities.

The White Paper makes a number of other important proposals for reform and I shall listen with interest during the afternoon to your Lordships' views upon them. But perhaps I may mention only one more. I think that among the most important proposals are those designed to make primary health care services more responsive to patients and more cost-effective, building on the Government's earlier White Paper Promoting Better Health. The Government will take care to ensure that these changes are implemented in a way which is sensitive to the circumstances of general practitioners in rural areas. In particular on this point, my right honourable friend the Secretary of State has already made clear his view that a higher basic practice allowance will be needed in scattered rural areas than in many other places.

The White Paper makes clear that much detailed discussion will be needed with National Health Service managers and professional staff about the implementation of these reforms; reforms which incidentally and very importantly apply to Scotland, Wales and Northern Ireland and which are dealt with, as your Lordships will know, in chapters 10, 11 and 12 of the White Paper. But in order to pursue this consultation process, and to assist these discussions, my right honourable friend has now published a series of working papers, which I realise your Lordships will not have had very much time to consider.

I recognise, as the noble Lord, Lord Ennals put to me, that we are setting ourselves and the National Health Service a challenging timetable to achieve these changes. But we are doing it because we believe that where decisions are taken by those most directly involved in managing and in giving care to patients this is the best recipe for seeing that the interests of the patients come first. I am sure that that is the right way to proceed and I am confident that the service will rise to the challenge.

3.55 p.m.

Lord Ennals

My Lords, this is one of the many occasions when your Lordships' House has had good reason to be grateful to the noble Lord, Lord Hunter, for facilitating a crucial debate at a crucial time. His decision to initiate the debate may well have accelerated the publication of the eight working papers, although they have done very little to clarify most of the fundamental questions.

The debate is taking place in an atmosphere of some confusion and uncertainty. I must say that there is deep scepticism about the Government's intentions and some anger that, as with so many issues these days, the Government are embarking upon a journey with only the haziest idea of how to get to their destination. No wonder the noble Lord, Lord Hunter, the fairest of men, was so critical of this document and of the lack of consultation and involvement. He put the National Health Service into its historic perspective, and he is one of the best people to do this.

The noble Lord used the phrase "the end of the beginning". Our fear on this side of the House is that the current proposals may signal the beginning of the end. He suggested that the proposals were evolutionary. This was one point on which I disagreed with the noble Lord, Lord Hunter. I think they are not evolutionary but far more drastic than that. If carried through with all the intentions that the Secretary of State made clear on Monday, the proposals would dramatically change the face of the National Health Service as we know it.

The Leader of the House was very bland in his speech. I do not think it is wise to underplay or to play down the radical nature of the proposals under debate. The future of the National Health Service is very close to the hearts of the British people. No wonder! It has magnificent achievements to its credit with nearly half a century of service—a monument to social justice and to the Labour Government of the day when it was created. I think it may be that which hurts the Prime Minister.

What most people see in the National Health Service—an embodiment of social justice—is anathema to her philosophy. It is not that the great British public are uncritical of the service; they criticise the lengthening waiting lists. They criticise ward closures and under-funding. In fact, as your Lordships may recall, these were the issues that led the Prime Minister to establish the review although none of those vital issues is dealt with in the White Paper.

The public have tolerated a succession of Conservative reorganisations over the past 10 years and more. Frankly, those reorganisations have not achieved much in terms of an improvement of the National Health Service but I emphasise that none of them has challenged the basic principles on which the National Health Service was founded. However, throughout this period of Conservative reorganisation there has been the lurking fear that one day an over-confident Conservative Government would decide to introduce its free market, profit-orientated dogma into our National Health Service. That is why there has been a suspicion that the National Health Service is not safe in the hands of the Prime Minister. I must say that today it is no longer a suspicion, it is a certainty.

I believe that the National Health Service is now threatened. It is quite clear in my view that in the three weeks since the White Paper was published the Government have failed to persuade the bulk of the electorate and a substantial part of their own party that the proposals contained in Working for Patients and its eight working papers are satisfactory or would help to improve the National Health Service. I think they see the proposals as complicated, confusing, dogmatic and ill-thought out, and they would not result in better service to the patients.

According to the Gallup poll last week, more than two-thirds of those asked saw the proposals as the thin edge of a Thatcherite privatisation wedge, including 46 per cent. of those Conservatives who answered the questions. They are quite right. I believe that this would be the beginning of the end for a service based on patients' welfare. In my view the proposals put producers before patients and profits before people. With these proposals now out in the open, it is quite clear that the National Health Service is no longer safe. I prophesy that it is this issue more than any other that will bring down the Government.

There are two debates at present proceeding on the Government's proposals. One concerns the proposals themselves and the other concerns the way in which the Government are proceeding to act to ensure that the White Paper proposals, however objectionable, unprincipled or impractical, are carried in to effect without any delay. I should apologise that I asked the noble Lord the Leader of the House a question from a seated position. I asked him why he was proceeding so quickly. I do not think he gave an answer. I hope that at some stage there will be an answer.

Lord Belstead

My Lords, I did give an answer.

Lord Ennals

My Lords, the answer that the noble Lord gave was that the Government were proceeding quickly in the interests of putting patients first. I agree with putting patients first, but let us get the pattern right. If proposals are going to be put before your Lordships' House let us all, and everyone involved in the National Health Service, the professionals, the patients and the community organisations, have an opportunity of seeing that if there is to be a change it will be for the better and not for the worse. It would be better to leave some time for consultation than to adopt a rushed-through procedure.

I suspect that most people involved in this debate will concentrate on the proposals themselves. Therefore, I want to begin by challenging the Government's approach to the current debate. The review itself was secret. It was carried out by politicians and civil servants, many of them with little experience of using the National Health Service. There was no real consultation with doctors, nurses, the members of professions complementary to medicine, those representing the ancillary workers, the many voluntary organisations, the health service administrators, the pharmacists, the dentists, the universities—the noble Lord, Lord Hunter of Newington, mentioned the universities—let alone representatives of the consumers or the local authorities.

Working for Patients should have been a Green Paper, open for consultation. But it seems as if the proposals are graven in white marble. It was reported in the press that at his press conference on Monday the Secretary of State said that he welcomed: contributions, constructive criticism and alternative suggestions, so long as they are aimed at putting the White Paper proposals into practice by 1991. Most people in the health service recognise that these reforms have to happen". That means that he is going to push the White Paper through as it is. That is no way to deal with our National Health Service.

As the Secretary of State presented the eight working papers, he was quite unrepentant that those papers leave many fundamental questions unanswered. Apparently, according to an internal Health Department document, there will he 29 project groups which will "work through the changes" that are proposed. The press article further stated: Civil servants will draw up project briefs—for self-governing hospitals, GP budgets, consultant posts, medical audit and others—including how much the plans require 'consultation; discussion with interested parties, or formal negotiations'. The document adds: 'The Secretary of State is anxious to minimise the latter which could seriously slow up the process of implementation'. The words "the latter" refer to consultation. I repeat my belief that that is quite the wrong way to go about changing the National Health Service which has been in existence for more than 40 years. This approach is unacceptable. These proposals will have to be very carefully considered.

One of the few NHS staff associations. the Institute of Health Services Management, in commenting on the Government's proposals said: They still seem to leave fundamental questions unanswered about the impact of these proposals". I hope that some of the fundamental questions that will be put during this debate will be answered in the wind-up. Maureen Dixon, the institute's director, said: None of us can yet say what the effects will be on a particular community or local population. Let me give a clear assurance to the Government that, having looked at some of the proposals, from these Benches we shall subject every proposal to the most careful scrutiny. We shall require much more information on the proposals. We shall take maximum care to ensure that the House is not faced with attempts to push things through. During the course of the next few months we shall need to have a great deal of the uncertainty removed.

The Government must accept that so far they have very few friends among those who care about the nation's health as opposed to the profit fanatics. It is very clear that throughout the National Health Service, and most of the organisations involved in it, a great deal of uncertainty exists. I draw the attention of the noble Lord the Leader of the House to a leading article in the Journal entitled Health Services of 2nd February which stated: In future years people are likely to look back on the halcyon days of a pre 1989 NHS, which provided straightforward services to the public, before fragmentary and diversionary market forces intruded.

You went to your GP. They either treated you or passed you on to a trusted consultant colleague for further treatment in the hospital service. The problems and anxieties of being ill were not compounded by a complicated system which was more preoccupied with making a fast buck than providing for needs comprehensively … The publication … of the government's white paper is likely to mark the turning point when the enduring simplicity of the NHS concept is abandoned in favour of a confusing diversity. The journal's editorial concluded: The White Paper as it stands is largely bad news for the patients and NHS staff but very good news for the accountants". It is not just the health service press which has been very critical of the proposals that have been presented. Doctors have been extremely critical. I noted that Dr. Paddy Ross, on behalf of the BMA consultants, condemned the plans as "Right-wing nonsense". The ethics committee chairman, Dr. Alexander Macara said: These proposals are made by people who know the cost of everything and the value of nothing". The director of the Association of Community Health Councils in England and Wales dismissed the emphasis on patient choice as 'rhetoric' and predicted that consumers would have less choice when hospitals and GPs opted out". The Health Visitors Association has joined in the criticism. Mr. Trevor Clay, the general secretary of the Royal College of Nursing said: Nothing in these papers removes the fear that we could be heading for a two-tier system with all new developments and the best staff sucked into the trust hospitals". Those views represent many of the genuine fears that the proposals will drive the National Health Service towards a two-tier service. The Government should be clear that the criticisms which are made—I suspect they will be repeated by some noble Lords today—are not just the criticisms of a bunch of left-wing critics. I believe they go very widely through the people who thoroughly understand the working of the National Health Service.

Through my involvement with the College of Occupational Therapists, I have discussed the White Paper with staff at the college and with members of other professions. They too comment on the absence of proposals for the care of children, the elderly, the disabled and the mentally ill. The White Paper is all about acute treatment. The professions complementary to medicine seem to be completely ignored. However the White Paper mentions speech therapists and physiotherapists in the context of the Government's wish to see more untrained and more unqualified staff introduced into the National Health Service. In my view that is a quite retrograde step.

Among those therapists there is much cynicism about the Government's constant repetition of references to value for money when there seems to be so little concern for that vast army of patients, mainly the elderly and the handicapped, who can never offer value for money. They are always the people who have to be most protected. They are the people who seem to be forgotten in the new kind of National Health Service which is proposed.

The proposals for the opting out of what originally seemed to be about 250 to 320 big acute hospitals now seem to have spread to the possibility of all hospitals opting out, and indeed to community-based services and clinics having the opportunity of opting out. Mr. Clarke said on Monday: Any hospital within the service is potentially capable of becoming self-governing". If it were to be the case that over the next few years almost all the units of the National Health Service decided to opt out there would not be a national health service. There would be scatterings of small hospitals and small units. That is what we escaped from nearly 50 years ago.

I looked at the working document on the self-governing hospitals. On page 5 some of their delegated powers are listed. They include the power to negotiate the price of services; to generate income; to acquire, own and dispose of assets; to borrow; to retain operating surpluses and to build reserves; to set out their own management structures; to employ whatever, and however many, staff they consider necessary; to determine pay and conditions of service; and the freedom to employ and direct their own medical and nursing staff. There is one sentence only about providing services. That sounds like a management oriented service. I find it horrific when I think of the nature of the National Health Service as I and many of your Lordships know it. I think that the Government will have to think again.

It is sheer nonsense for the Secretary of State to say that those opt-out powers are something other than opt-out powers. He suggests, and the Leader of the House said today, that the hospitals will all operate within the National Health Service and that there will not be a break-up of the National Health Service. I say again that if units up and down the country, big and small, opt out of the supervision of health authorities—apart from certain conditional powers held by the Secretary of State, which are unlikely to be used—there will be a fragmented service.

Who will take the decision as to whether a hospital opts out? I cannot tell from the document. To whom will they be accountable? Who will appoint the new directors? What authority will they have? What relationship will they have to the people whom they serve?

Although I shall not go into the details I believe that there is the same degree of concern in relation to the proposals put forward in respect of general practitioners. What training do they have for the kind of accountancy work proposed? I believe that the proposals put forward both in terms of general practitioners and hospitals will create a massive bureaucracy. I believe that the National Health Service has managed over the years to keep the amount of money spent on management to a very small proportion, even compared with the private sector.

A noble Lord

Rubbish!

Lord Ennals

It is not rubbish. The proposals will increase the bureaucratic proportion of the costs of the health service. That is the pattern in the United States. I believe that the Government have come up with ill-conceived and unproven proposals. I believe that most of them are unworkable.

In conclusion, I plead with the Government to think again about many of the proposals that have been put forward. I do not mind some experiments nor some new practices in the National Health Service. Let us try out a new plan, if it is a good one. Let us see if it is a good one. But I believe that it would be fundamentally wrong to base a massive reorganisation of the National Health Service on unproven, suspect dogma. I believe that that would be an irresponsible act on the part of the Government. It is because of the apparent intention to rush the proposals through that we condemn the White Paper as it is currently presented.

4.13 p.m.

Lord Winstanley

My Lords, I shall begin by apologising to your Lordships for addressing the House with an appalling cold for which neither the National Health Service nor the private sector can do anything at all. I mention that fact to demonstrate that doctors are as delighted as anyone else to discuss their own ailments.

We are now in the midst of the debate for which almost all of us called at the time of the recent Statement on the National Health Service review. Particular thanks are due to the noble Lord, Lord Hunter of Newington, for enabling us to have this debate so very soon.

We also owe special thanks to the noble Lord the Leader of the House for responding so rapidly to the demand at the time of the Statement that there should be a debate. He has clearly demonstrated that he knew that there was a need for a debate and as Leader of the House would see that it was held. We are also grateful to the noble Lord for taking part in the debate and for some of his remarks which demonstrated his commitment to the National Health Service and its fundamental principles.

Perhaps we should also thank the noble Lord the Leader of the House for making special efforts—as I think he did—to ensure that in addition to the White Paper we had the eight additional papers in time to read some of them before the debate took place—although perhaps there are those of us who rather wish that we had not had them. The fact that we received them on Monday was in part due to the efforts of the noble Lord and in part to those of the noble Lord, Lord Hesketh.

I think that the noble Lord, Lord Hesketh, deserves not only our thanks but also our commiserations. Having left the DHSS as a Minister on Monday, he had to stand at the Dispatch Box to defend the indefensible, the Football Spectators Bill, in which your Lordships were asked to support a draft scheme which not only had we not seen but which had not yet been drafted. Now the noble Lord has been dragged back to the department which he left to answer what will be an extremely complex debate and perhaps to try to make sense of the unintelligible. I wish the noble Lord luck.

With 29 speakers in the debate, I think that it behooves those who are privileged to speak early to exercise some restraint so that others who will make enormously important contributions will be able to expound their views fully.

Like the noble Lord, Lord Hunter, and the noble Lord the Leader of the House, I should like to consider briefly the history of the National Health Service, and perhaps also the history of Mrs. Thatcher's National Health Service review. The present structure of the National Health Service, with all its many defects—and I acknowledge that it has many which require remedy—has evolved gradually and steadily over a period of more than 40 years. As the noble Lord, Lord Hunter, made clear in his speech, it emerged from a patchwork of provisions: the old Lloyd George scheme, the panel doctor, the voluntary hospitals, the municipal hospitals, the hospital Saturday fund and many other provisions.

Turning to the history of the review, we go back to a time when there was widespread public anxiety about the state of the National Health Service, the recognition by government that it was an electoral liability and that it was time something was done, and a firm decision by the Prime Minister that there should be a review of the National Health Service. I think that she believed that by establishing that review she would at once stifle criticism and perhaps allay anxiety.

Following announcement of the review, it seemed that nothing happened. It may have been that things were happening in the obscure corridors of power, but we did not hear that anything was happening. Then there was a ministerial reshuffle, with the result—which I personally welcome—that Mr. Kenneth Clarke became Secretary of State for Health.

For the first time for a very long period we had a Minister of Cabinet rank responsible for the National Health Service. That was something we had not had in the past and which I regretted. I believe that the morale of the National Health Service declined steadily after the creation of that huge conglomerate the Department of Health and Social Security that lumped pensions and social security in with the National Health Service. That is not intended as a criticism of those who were responsible for that department—the noble Lords, Lord Ennals and Lord Joseph, Mrs. Castle, the late Mr. Richard Crossman. However, I believe that the health service needed a Minister of Cabinet rank and. I welcomed the appointment of Mr. Kenneth Clarke in that capacity. I accept that Mr. Clarke as Minister is totally committed to the principles on which the National Health Service was founded and to the continuation of the National Health Service along those lines.

When he arrived at the department, what did he find in the way of a review? I do not know, I was not there. I suspect that he found a blank sheet of paper and found it necessary to write on it or to cause words to be written on it. The words that have been written on it are these—a vast amount. The documents are very cleverly written. Almost every fourth paragraph spells out that the object of the exercise is the preservation and protection of the National Health Service. The three paragraphs in between spell out steps which could undermine the National Health Service.

I agree with much of what is suggested but I have very grave anxieties about the timescale of the operation. Each of the eight papers begins with a paragraph which reads: These papers describe in greater detail how particular proposals in the White Paper "Working for Patients" will be implemented, and will form the basis of further discussion with interested parties. Many of the White Paper proposals will depend on primary legislation. The Government intends to complete discussions on any such matters by May 1989 to enable preparation of the necessary legislation". In 14 weeks we shall be in June. By the end of this debate we shall be getting close to May. Who are the interested parties with whom discussions have to take place? There is a whole conglomerate of measures on almost every page which will have to be discussed with doctors, surgeons, nurses, physiotherapists, radiographers, pharmacists and all the different workers.

Last night, in common with other noble Lords who are present, I had the honour to be present at the annual dinner of the PSNC—the Pharmaceutical Services Negotiating Committee—at which the guest speaker was the Minister for Health, Mr. Mellor. It seemed to me that he had a pretty rough ride. If he and other Ministers honestly believe that all the Government's present problems with the pharamacists—who are an essential part of the family practitioner committee services which are dealt with substantially in these reviews; there are major changes with the introduction for the first time of cash limits to family practitioner committee services—will be solved satisfactorily and amicably by May, they will have to think again. I do not see how that can be done.

As the noble Lord, Lord Ennals, reminded us, the time for the legislation finally to be in place is 1991. That is a little further off, but I do not see how this can be done. There will have to be discussions with doctors and nurses and calculations to cost everything. How much does a hip replacement operation cost? How much does this cost; how much does that cost? If all those discussions have to be completed by the end of May, no one will receive any medical treatment. All the doctors and nurses will be having discussions. There would be no other way in which they could achieve that. I do not believe that the proposal is feasible.

Let me make it clear that I do not wholly resist all the proposals provided that they are brought in sensibly with proper discussion and not with the kind of indecent haste suggested by these procedures. I agree with much of the review. Let us take one item. I have argued for many years that it would be necessary sooner or later to embark on cost-effective studies in relation to medical procedures. It seemed to me that all we doctors, other medical staff and patients had to accept that resources were finite and necessarily limited.

We also had to accept that other government departments required resources. Many of us accept that the health of all individuals depends not only on the National Health Service but on other things. As Her Majesty's Government now know, it depends very much on food, education and housing. Other government departments require resources. When the cake has been divided and the National Health Service has its slice—which will not be as large as it wants and will never be enough to do everything that everyone believes should be done for every individual—sooner or later you must embark on cost-effective studies in relation to medical procedures. Those limited resources can then be focused as far as possible on those areas in which there is the most dramatic return on the investment in terms of the relief of human suffering and the saving of human life.

I support the idea of cost-effective studies, but let us consider the matter in some detail. How do you calculate the costs? To calculate the cost of a hernia operation, let us take the example of an elderly chap who is a manual worker and has an irreducible inguinal hernia which is not life threatening so he is down for a non-urgent operation. The urgency of an operation depends on who is to have it. If any one of your Lordships were to have such an operation, we would perhaps not think that it was so non-urgent after all.

However, if that person has to wait two years for his operation and is unable to work during that time, the state—the Department of Health or the Department of Social Security—will have to provide for his wife and children. Is that included in the sum? If it is included in the sum, how is it included? How do you work out the cost of a hip replacement operation? One patient may have post-operative difficulties and have to remain in hospital a great deal longer than another person. Another may have rehabilitation difficulties and require a prolonged period of physiotherapy.

The calculation can be made only on the basis of a vast examination of all cases and by taking average figures. It has already been done very thoroughly in relation to heart transplant operations. It has taken a long time and a great deal of resources and energy. All that must be done, but can it be done by the end of May? I do not think that that is possible, but much of it will certainly have to be done long before the legislation is introduced—we are told that primary legislation will be necessary for many of these proposals to go ahead—and carried through both Houses.

Perhaps we may look for a moment at cash limits on family practitioner committees. I do not believe that this or any other government can predict with certainty how many people will have which illnesses and at what cost in any future period of 12 months. There will inevitably be errors. The noble Lord knows that there have been errors in the past. When the family practitioner committee services had exceeded what was budgeted or expected because of special circumstances such as an epidemic—they could not exceed cash limits because there were no cash limits—the Government had to recover the money from the only source available.

That was their cash limited services—the hospital budget—and they made a 5 per cent. cut in the hospital budget. The net result was that the hospitals provided fewer services so the family practitioner committee services overspent by a further amount the following year. Then you have to take another 5 per cent. from the hospital budget so you finish up with no hospital budget left from which to take 5 per cent. or any per cent. at all.

I accept that that situation could not be permitted to go on. I therefore accept that there is a need to look at cash limits in relation to family practitioner committee services. However, it could be very damaging if we were to go back to a situation, or if the public are led to believe that we are to go back to a situation, that we certainly had in the past before the new contract to which the noble Lord, Lord Hunter, referred. That was the situation in which the general practitioner who gave the worst service, kept poor records, had no secretary or receptionist and had inadequate surgery premises was the best off, whereas the general practitioner who did the best work and the most for his patients was the worst off.

It could be damaging if people are encouraged to think that under this new system the doctor will somehow be influenced not so much by what is in the best interests of an individual patient, but what is cheapest and in the best interests of his own practice's budget and perhaps, in the end, his own practice's pocket. It does not need to happen, but we need time to spell out these arrangements and to work them out. I do not think for a moment that the Government have allowed themselves the necessary time to deal with those matters.

There are other points that I wish to make. I have read all these papers, but you would think that Sir Roy Griffiths had never conducted any review. How can you review a National Health Service without catering fully and completely for community care, which is an essential part of the present Government's programme and a very necessary part? I do not complain about that in this debate because I am sure that we shall have a detailed response in due course, but the matter will have to be considered in relation to all the other papers.

How long will the proposals take to implement? Who will work out the cost of every operation? If I may be forgiven for reminiscing about my earlier days, a long time ago I worked in a municipal hospital—Hope Hospital in Salford, which was run by Salford city health committee. That committee reviewed its expenditure annually. I clearly remember being an observer at one of its budgetary meetings when Alderman Haynes, who took a great interest in health matters, queried the cost of perineal repairs. A perineal repair is a repair that a woman may require after delivery and confinement if there has been a tear or laceration which must be sutured and repaired.

Alderman Haynes said, "This item of perineal repairs crops up every year and every year it gets more and more. If we have to have all these repairs to these perineums, why can't we get some decent ones and be done with it?" I do not suggest that this exercise will be carried out by aldermen in Salford or anywhere else, but I do suggest that it will have to be carried out by someone and it will take a long time. The person responsible will not complete the exercise within the time-scale that the Government have in mind.

Let me make just one more observation on the subject of the hospitals becoming self-governing. What is to be the position of the university hospitals, the medical school hospitals and teaching hospitals? I know that Sir Mark Richmond, who is not only chairman of the Committee of Vice-Chancellors and Principals but also vice-chancellor of the University of Manchester, has made the point to Ministers that Manchester University medical school has four teaching hospitals. One wonders what the position will be if one of them decides that it will become self-governing and the others decide that they will not. How can a teaching hospital become self-governing if much of its work is to be governed by the university—and it cannot fail to be so? There is no answer to problems of that kind spelt out in those papers, but they will have to be answered.

I come to my last point. I note the inducements to elderly people to join the private sector. I believe that such inducements will be in vain because most elderly people cannot afford private medicine. In its early days the private sector medicine was extremely profitable because it catered almost exclusively for rich and healthy people. Once the private sector has to take on all the employees of a certain firm and all the members of a certain trade union, and if later it has to serve elderly people, then it will be in precisely the same situation as the National Health Service has been in since 5th July 1948. It will have a bottomless—if you like open-ended—commitment to everybody to do everything. It will not be able to do it. The small print in private sector undertakings will swell, exclusions will increase and the costs of the private sector will grow.

In conclusion, it would be ironic if a review which some people feared might spell catastrophe for the National Health Service turned out in the end to ring the death knell of the private sector.

4.31 p.m.

Lord Richardson

My Lords, in common with many of your Lordships I felt considerable gratitude toward the noble Lord, Lord Hunter, when I saw that he had tabled this Motion so quickly after the publication of the White Paper. Like the noble Lord, Lord Winstanley, I feel acute anxiety over the timing of discussions, having experienced the telescoping of time by successive governments in the discussion of important matters relevant to medicine and the health service.

When the noble Lord, Lord Hesketh, read out the Secretary of State's Statement to the other House, it seemed to me that the following paragraph was central: All of our proposals share a common purpose—to make the health service a place where patients come first and where decisions are increasingly taken at a local level by those most directly involved in delivery and managing care".—[Official Report, 31/1/89; col. 1002.] Ever since the health service was first discussed and was just an idea—in the 1940s, and even in the 1920s when that distinguished Member of your Lordships' House the late Lord Dawson of Penn made most valuable proposals—it has been axiomatic that patients come first. That is axiomatic for doctors when they are undergoing training and in practice. The place where decisions should be made was also a matter of considerable concern in the 1940s, when a very strong preference was expressed by another Member of your Lordships' House, the late Lord Moran, on behalf of the Royal College of Physicians, supported by the rest of the profession, for control by the Ministry of Health rather than by local authorities. It was wished to avoid local politics interfering with the service locally, or at any rate obtruding on it.

These government proposals push that point further. I hope that they are capable of overcoming one disadvantage which resulted from that desire to limit local political influence; namely, that it limited—at least in my view—a personal sense of pride and interest in local hospitals. The hospital that used to be "our" hospital steadily became just "the" hospital. Of course there were exceptions, such as small hospitals in country districts and great and famous hospitals which had a large emotional attachment largely due to their teaching and research expertise.

The advice that will now come locally must be even stronger than it has been in the past because of the movement toward local control without local political influence. Mr. Bevan recognised very clearly the importance of upgrading the local hospitals by encouraging consultants to go there and remain in the hospitals. In answer to a letter from the three presidents of the Royal Colleges—and it was a famous letter in modern medical history—Mr. Bevan replied: I am confident that round a table we shall be able to make satisfactory arrangements which will encourage specialists to work within the precincts of hospitals". That was difficult to do at that time. Depending on private practice, consultants in those days moved between several hospitals. In London their consulting rooms, and in some instances private beds, were a considerable distance from their main hospitals. That situation is less prevalent, but I hope that any organisation will take on board the virtue not only of keeping private beds in hospitals (a difficult battle that seems to have been won) but also of setting up consulting rooms and even private hospitals in close propinquity to the main hospital. The contracts of consultants will be examined and made tighter.

After 30 years of experience as a consultant in the health service and for some time before that I have absolutely no doubt that the vast majority of consultants not only give excellent and expert service but a great deal of their time for which they are not paid. For years and years they never realised that they were not being paid because it was part of the old voluntary system. I still believe that some of the attitudes that obtained with the voluntary system have been handed down and persist strongly among the consultants of today. I greatly hope that when the contracts are considered not only the vast responsibilities of clinical work, teaching and research—to echo the words of my noble friend Lord Hunter—but the opportunity for voluntary contribution of time and energy in the clinical field as well as all the administrative areas will be remembered, as also will what I think is the exciting business of audit. The noble Lord the Leader of the House seemed to think that audit would be rather dry. It may well be so for those who are not actually participating, but I believe that to have one's performances compared with those of one's peers could be exciting, if not alarming.

The merit award system has survived in spite of its eccentricity, and is under review. I see little to question about the proposals in relation to that. There is just one exception: that is, that those who get an increased merit award have to serve for three years before the benefit of that award spills over into their pensions. I have no doubt that is perfectly all right for the higher awards. Those who are outstanding people and who are still contributing—that question of still contributing is part of the new proposals—will clearly get their higher awards when they are relatively middle-aged.

However, there are cases—I speak from experience—where the "C" awards, the less certain and less obvious awards, have been made very late for inadvertent reasons or not very good reasons of a personal nature. I should like to suggest to the Government that those who get "C" awards should be able to have those awards computed with their pensions, even if they have not served for three years.

I think the proposals are difficult to envisage, and however clear the explanations it is difficult to see how they actually work. But having worked in a teaching hospital that was self-governing, I see no difficulty for a hospital, at any rate of that size, to continue to govern itself. This was so of all the teaching hospitals. They were within the National Health Service and, as the noble Lord the Leader of the House has told us, they will remain so. That was the case for approximately the first 25 years or more of the National Health Service. Those of us who worked in such a hospital found no disadvantage in that system, but we found considerable disadvantage resulting from the change in organisation that took away our government.

Finally, I hope that all the emphasis on administration—I am very much disposed towards administration by doctors, having been concerned as long ago as 1967 with the cogwheel reports which started off the idea that doctors had an obligation to administer—will not blur the true professionalism of the medical profession and make its members into bearers of a more bureaucratic attitude because, when you think about it, it is the medical expertise and dedication of doctors, as doctors, that is the only absolute necessity in the health service.

4.44 p.m.

Lord Flowers

My Lords, I too welcome the timely initiative of the noble Lord, Lord Hunter of Newington. I also welcome the Government's commitment to the National Health Service, as clearly expressed today by the noble Lord, Lord Belstead, the Leader of the House.

I find much to praise in the White Paper although, like the noble Lord, Lord Ennals, I wish it were green. It is positive; it recognises strengths as well as weaknesses; it sets out the Government's objectives for reform clearly and optimistically; and it proposes an administrative framework intended to contain them. It does not meddle with detail. I found it impossible to ignore the contrast with the muddle of the Government's earlier education papers, which gave us so much trouble in your Lordships' House last year.

Some people complain that the Government's main objective is to commercialise the health service. That comes oddly, especially from those who profess to believe in a market economy. They complain that it will introduce a two-tier system: one for the rich or insured and one for the poor and uninsured. But there are already many tiers in the health service, depending on how much you wish to pay for extra benefits. What we should expect of reform is that urgent cases will continue to be dealt with urgently; that waiting lists will be shortened; that the dedication of the employees will not be crudely exploited; that the health of the nation will be improved; and that patients and their families will be treated with compassion. If business criteria can help to bring that about—and I believe they can—all well and good; but they are not an end in themselves.

A little more detail has just been published in the working papers, although the broad-brush treatment seems to have been continued. However, I find it surprising that no attention at all seems to have been paid to comparisons with health services abroad. I hope that the Government can explain why in Britain we are so far down the list of well supported health services and I hope they have noted that the commercial practices of Canada do not seem to lead to the excesses sometimes seen in the United States.

However, I must press on to other matters that have received scant attention: namely, teaching and research. These are touched on briefly in paragraph 4.29, although paragraph 4.30 promises more when the Inter-departmental Steering Group on Medical and Dental Education has reported. Of course I welcome the clear statement of commitment to these matters made by the Leader of the House.

I was a member of your Lordships' Select Committee on Science and Technology when we reported last year on priorities in medical research. I may be the only member present today who took part. At any rate our chairman, the noble Lord, Lord Nelson of Stafford, has asked me to say how sorry he is that absence abroad prevents him from speaking today. He has also asked me to make a statement on his behalf and I am very happy to do that because I entirely agree with him.

We are particularly disappointed that there is so little mention in the White Paper of the important part that research within the National Health Service can play in achieving the Government's objectives. The Select Committee identified a clear need for the NHS to have an adequate research effort of its own, particularly in the fields of clinical research and health service research. As we said in our report: The NHS exists to promote the improvement of the nation's health; medical research has an important part to play in achieving that end; the NHS should therefore play a part in supporting medical research …There is no lack of push from medical researchers in the United Kingdom; what is missing is enough pull from the NHS". It is not enough, and we said it very clearly, that the National Health Service should have to rely upon the excellent basic work of the Medical Research Council, coupled with the insignificant efforts of the Department of Health. It is the health service itself that needs the research; it is the health service itself that should be empowered to perform it or commission it.

When the Government eventually reply to the Select Committee's recommendations, we shall particularly wish to see in organisational terms how the research needs of the National Health Service are to be identified and satisfied. That cannot be done by departmental civil servants out of contact with clinical realities: it must be done by the National Health Service itself.

The appointment of a chief executive and an effective management responsible for the running of the health service, proposed in the White Paper, is of course warmly to be welcomed. I venture to suggest that this provides the opportunity to appoint a director specifically to carry out the responsibilities for research outlined in our recommendations. It is not quite the national health research authority that we sought, but it would be a significant step in that direction.

Had the White Paper been a little more explicit about research it would no doubt have referred to the growing importance of the medical charities in supporting it. In total they spend about the same amount these days as the Medical Research Council. Policy for medical research therefore has to take into account the activities of charities. That is why we recommended that the annual stocktaking of research held under the auspices of the health departments should be expanded to include the work of the medical charities. Of course, it should in future include the research that I hope will be undertaken by the National Health Service as well. It is not enough that the cosy relationship between the departments and the MRC should continue in the convenient absence of the other major players.

I should like to end with a few words about the teaching hospitals although I will not repeat the remarks of the noble Lord, Lord Winstanley, with which I agree. The teaching hospitals appear in the White Paper somewhat as an afterthought. Certainly they complicate the issue because medical students are taught their clinical medicine by both academic and NHS staff, and clinical research as well as patient care takes place in teaching hospitals.

The special arrangements required to deal with the overlapping activities and responsibilities for education, research and health care were carefully discussed in the report. We must take care that a more commercial approach does not militate against medical education and research in much the same way that local and immediate needs for clinical services already conflict with the national and longterm priorities of the teaching hospitals.

Let me be positive about it. As the noble Lord, Lord Hunter of Newington, explained, the special increment for teaching—SIFT—was introduced to recognise the special nature of a teaching hospital so far as teaching is concerned. In the report the Select Committee proposed its extension to cover research also. Indeed, the future of SIFT is now being considered by the steering group referred to in paragraph 4.30 and by the noble Lord, Lord Belstead. It is of course necessary now to re-examine the matter in the new context of the White Paper.

The SIFT mechanism could be used to ensure that appropriate priority is given to education and research if medical and dental schools were empowered to act as its purchasing agent. I suggest that the whole of SIFT should be deployed by the universities themselves. This would ensure that appropriate facilities were provided for undergraduate teaching and research, and the related additional costs that always occur in teaching hospitals would be covered.

One must also consider the governance of a teaching hospital. Paragraph 3.4 of the White Paper discusses the composition of the board of trustees of an NHS hospital trust. Regarding a board with no more than 10 directors, excluding the chairman, it says: for teaching hospitals the non-executive directors will need to include someone drawn from the relevant medical school". Someone, indeed! This very singular provision would be totally inadequate for a teaching hospital trust and would certainly fail to reassure the medical and dental staff that the interests of teaching and research were even understood, let alone given adequate priority over service needs. In employment terms the position is bad enough already, with university and health service staff working side by side with quite different terms and conditions of service.

The role of research within the NHS and of the teaching hospitals in regard to both education and research is not to be treated as a mere afterthought. It requires far higher priority if the next generation of doctors, dentists and consultants as well as the future wellbeing of patients is to be protected and facilitated. In the White Paper the Government have affirmed their commitment to teaching and research. We warmly welcome that, but there is still a great deal to be done. The Croham Report identified major problems concerning the interface between the health departments and the education departments. The Merrison Report identified the same problems ten years ago. The Select Committee identified them also. They really must now be rectified, and it is a great pity that the White Paper does not say so.

4.56 p.m.

Lord Trafford

My Lords, I too am grateful to the noble Lord, Lord Hunter of Newington, for introducing the debate, which I thoroughly welcome.

I should declare an interest. All my professional life I have been a strong—indeed one might say passionate—supporter of the National Health Service and I continue so to be. I was therefore very pleased when my noble friend the Leader of the House started his introductory speech by emphasising that the White Paper underlines the significant and important principles that have underlain the National Health Service for the last 40 years—free at the point of access regardless of income, financed largely by public funds, dependent on need, not on wealth, and free and open to all. This will continue; this is guaranteed. I think that this point has been underrated. It was hardly mentioned in most of the comments made since the White Paper was published at the end of January.

Without going into the history of the health service, which we have heard a number of times, casting one's mind back five years one remembers the fuss that was made when a think-tank leak was said to have occurred, in which it was thought there would be dismemberment of the welfare state, damage to the National Health Service and so on, and policy units were publishing the most radical solutions to all our social evils. In fact, when the Prime Minister's review is published, all the principles underlying the National Health Service will be reinforced and restated. As a supporter of the National Health Service I regard this as a significant victory by all those who publicly or privately have tried hard to persuade her and her colleagues of the significance and success of—I rarely agree with the noble Lord, Lord Ennals, but I do on this occasion—and the liking of the public for, the National Health Service. That is a significant victory for those who feel and work for it.

The noble Lord, Lord Ennals, called for a lot more consultation and wondered why we did not have this. He gave an enormous list, which I think he said was not exclusive. It sounded to me as though he wanted a five-year long Royal Commission.

Lord Ennals

No, just consultation.

Lord Trafford

My Lords, there have been many inquiries into the National Health Service, and there is a mass of information available. I should have thought that the review had done rather well to have got as far as this in the time that it has.

If the noble Lord will read the papers he will find that the answers to at least three of the questions that he asked are in the working papers. They say who shall decide about a self-governing hospital; they say who shall decide about the chairman of the self-governing hospital committee and so on. I know that the working papers have been out only three or four days, but the answers are indeed stated. We must not set up ninepins that do not exist, and knock them down with magnificent rhetoric. The questions are in fact largely answered.

The noble Lord, Lord Winstanley, said it was difficult to price a hernia. I will leave aside his comments about Alderman Haynes. The noble Lord in fact priced a hernia. Of course it is possible to price a hernia operation and how much it costs to have people in hospital. This has been going on for a long time. Surely the noble Lord has heard of the initiatives. Surely he knows that we are spending a great deal of time these days, as more and more information technology is pumped into the health service, to know what is happening on costs.

One of the problems has been—I know the noble Lord shares this view with me—that previously we have never been able to identify what happens to the money that is put into the National Health Service. Nobody doubts that over the last few years there has been a need for some kind of reform. What we have been debating is what kind of reform.

Lord Winstanley

My Lords, will the noble Lord allow me—

Lord Trafford

My Lords, if I may finish this point I shall certainly give way to the noble Lord. We have needed some kind of reform and that is what we have been considering.

Lord Winstanley

My Lords, I am entirely aware that much of the work of costing operations has been going on. Indeed I have taken part in some. But the question I asked specifically—and perhaps I could repeat it if the noble Lord did not fully understand it—was in costing an inguinal hernia, does one include in that cost the amount of public money spent in keeping the wife and family of the person who has been waiting two years for the operation? That was the point I made.

Lord Trafford

My Lords, I take the point and I understood it. One of the major objectives of reducing waiting is the social cost of such operations, which is what the noble Lord is referring to. This is one of the most important elements in the National Health Service, but it is not the direct audited cost of that which happens within National Health Services premises, no.

There was no real doubt in anybody's mind about the need for some kind of reform. What was the central problem to which we should he addressing ourselves and to which the Prime Minister and her colleagues addressed themselves? It was surely that, however one tried to manage the service, resource allocation seemed to be wrong. Results did not come out. The outcome measurement was very poor indeed and, if you like, the quality control was not very good. In other words, the judgment of what we were achieving was also very poor. The information technology to which I have just referred was not there to tell us what was happening. The central defects were magnified by the fact that a hospital—which is the most expensive part of the National Health Service—is a whole series of barely related groups of people operating independently. There were nurses on one side, doctors on another and the administrators trying to pull it together and failing constantly because of various failures on the part of management. Those were the central defects that needed addressing.

As an example, taking the range of a particular costed element in a health service as 100, the range of the cost in different hospitals throughout the United Kingdom is between 54 and 135. There is an enormous range for apparently carrying out exactly the same type of service. The question that anybody would ask looking at an organisation is why is there this huge difference? Why do they spend so much less in Scarborough—I only mention Scarborough because it came out top of the list in one costing exercise—than they do in Nottingham? Why does this happen? What is the reason for the range. We are supposed to be equalising care throughout the country, so these are some of the things that desperately need to be addressed.

We have had four major management reshuffles and that has not solved the problem. So clearly taking the present management and tinkering with it will not solve the problem whether one puts in areas or takes them out, which we have done; whether one puts in districts (we used to call them HMCs), takes them out and then pushes them back in again 14 years later; whether one builds up the regional activity or cuts it down; whether one puts in general managers and so on and so forth. We often give these people responsibility which they have no powers to carry out. I shall not quote the famous remark made by Lord Baldwin when Prime Minister about power without responsibility; responsibility without power is the other way round.

In my view the White Paper addresses some of these central problems. It devolves downwards so that we do not have a massive centralised bureaucracy. One of the most remarkable things on reading it is how much power the centre is prepared to surrender. It is not usual when we sit here debating various Bills for the centre to be losing power; it is usually taking powers. On this occasion it is giving them up. They can devolve downwards lo the district, to the self-governing hospital, to general practitioners and so forth. The self-governing hospital programme in the White Paper is based oil two items: first, the Griffiths Report a 1982 on the appointment of general managers and, secondly, the use of budgetary centres which have been used experimentally in various hospitals. In some they are much more developed than in others. I am sorry that the noble Lord, Lord Winstanley, is not in his place because this is exactly the exercise that has been carried out for some considerable time. It allows some hospitals in this country to know almost exactly the cost of every item of expenditure, every test, every investigation and every operation.

One of the important points in the White Paper is the introduction and handling of capital charges because that shows us the true cost. Previously it has always been regarded as a free cost, but we should handle our land, our buildings, our properties and everything else in the National Health Service as a whole just as in any other organisation, but we have tended to neglect it.

These budgetary centres have made a huge difference. I shall quote one figure from one hospital. I could quote a number of others but one will give an example. A hospital was running its budget in 1984–85 into a deficit of nearly £5 million—it would have been called an overspend. Over the next three years—I shall not go through all the detailed processes—it introduced a full programme which is now run very largely by a doctor plus an administrator running a budgetary centre with a board; a board not altogether dissimilar from that upon which the noble Lord, Lord Flowers, poured scorn a few moments ago. It is run very successfully and includes a research programme. Indeed it is now breaking even. It is only 3 per cent. below the maximum number of patients it has ever taken in over the last 40 years. As far as I can see or have been able to find out there has been no change in quality.

That, therefore, is one of the reasons why this type of system in operation in a number of hospitals in different places is what the White Paper chooses to describe as the way forward for economic cost effectiveness combined with established quality of care.

I should have been very worried if the White Paper had stopped at "economic cost effectiveness". I would share the views of Members opposite who have been concerned about this. I am delighted to see the introduction of the Audit Commission—not just an auditor. I hope that noble Lords will read very carefully what the Audit Commission will actually be doing. Not only will it inquire into how units spend their money but it will also be inquiring carefully into how the services operate. There will be professionals, that is to say peer review, who can be instructed to go to X, Y or Z if there is some falling down on the job or the quality is unsatisfactory. I believe that is tremendously important. It is one of the most important safeguards that is written into the whole White Paper and not enough tribute is given to that.

I could go on for ever on this subject but I clearly realise that other people wish to speak so I should like to say two more things. First and foremost, "research" is a very emotive word. The Americans would say that you should never attack mothers or apple pie. But I shall make one comment about research. There is good research and bad research. There is worthwhile research and repetitive, pointless research which has all been done before over and over again. There is what is known in the profession as pot boiling and that unfortunately is what wastes a lot of time and money.

One therefore has to consider extremely carefully the type of exercise that we have been hearing about from the noble Lord, Lord Flowers, and the pleas for special services and special arrangements and so on. Nobody doubts the value of true, excellent research. It is fundamental. I was not surprised when the noble Lord said that medical researchers want more funds. I do not know anyone who does not want more funds for almost anything. The matter needs to be looked at just as carefully as every other aspect of expenditure in the National Health Service.

I should like to underline the most fundamental point of the exercise. This is a free choice. No district, no hospital, no general practitioner must follow the self-governing hospital. He does not need to do it. Let us assume that I work in Hospital A with this side of your Lordships' House and we decide that we do not wish to enter a self-governing exercise. We do not want to do these things: we do not have to. There is nothing in the White Paper which says that we must. Even if the Secretary of State comes to urge and persuade us, there is no way in which he can do so. All he can do is ask us to review our decision, and we may reach the same answer.

Alternatively, it may be that three hospitals wish to join together as an association—not altogether dissimilar from a present district—and operate such a service. They may do so, including community health—

Lord Ennals

My Lords, will the noble Lord give way?

Lord Trafford

In one moment. My Lords, they may do so. Therefore I emphasise that it is a matter of free choice: you can continue as you are or take a different course. The same is true of general practice.

Lord Ennals

My Lords, is not the important question: who within a hospital actually decides to opt out?

Lord Trafford

My Lords, it would be impossible to decide to opt out if any of the large segments of working staff within a hospital were against doing so. I could not operate a self-governing hospital without the consent of the nurses, the staff, the doctors and the administrators. It would not work; it would have to remain more or less the same. Many may do so for the good reason that, for once, they have corrected the membership and organisation of the district health authority.

Finally, it is easy to criticise, to pick holes in things and to say that much has been left out. However, the principles of the health service have been safeguarded. Opportunity is offered for the future with a free choice on that option. The White Paper contains much which will allow the National Health Service—which has been a great human experiment and success over the past 40 years—to continue to be a success for the next 40 years, or well into the next century.

5.12 p.m.

Lord Bruce of Donington

My Lords, I am grateful to the noble Lord, Lord Hunter, for having afforded the House the opportunity of discussing the Government's White Paper.

I feel a little sad about the occasion because, despite the soothing remarks which fell from the lips of the noble Lord the Leader of the House and other noble Lords, we are not here considering working for patients. We are really concerned with saving money and preparing for the commercialisation of the National Health Service.

By a geographical accident, when the House of Commons was destroyed and its Members sat in this House, I sat in approximately the same position on 26th July 1946 for the Third Reading of the National Health Service Bill. I sat behind my late right honourable friend Aneurin Bevan, the founder of the National Health Service—

Lord Trafford

He must have been on this side of the House.

Lord Bruce of Donington

No, my Lords, he was sitting here. I remember it well. Mr. Speaker was sitting there, by the Bar. No less than 20 Members of your Lordships' House were present for the debate. There were 13 Members from this side of the House—then the Government—and seven members from the other side of the House. I am happy to say that I can see many of them present today. In their own spheres and in their own parties they have become distinguished political figures.

I remember the day well. We had had many weeks, indeed months, of going through the National Health Service Bill. I was honoured by being privy to the thoughts on the issue of my right honourable friend and his colleagues. I do not wish to make an antagonistic or controversial point. It so happened, and I say this for the record, that the Opposition voted against the National Health Service Bill at Second Reading. It fought the Bill clause by clause and line by line in Committee. It voted against the Bill on Report and, uniquely, voted against it at Third Reading.

I make no particular complaint about that, except to indicate the fact that the differences of philosophy were profound. They were adequately expressed by many distinguished speakers, some of whom have since entertained your Lordships on a variety of topics. But they did not like it. They did not like the idea of a national health service because, as my noble friend Lord Ennals pointed out, it was essentially a Socialist measure.

Today, as I shall show, the word "Socialist" sticks in the gullets of a number of people to the point almost of sending them into apoplexy. After the initial settling in of the National Health Service there were further negotiations with the profession before vesting day. Despite all the predictions, it will be remembered that 97 per cent. of the population joined up within approximately seven months and the vast majority of the medical profession likewise.

The main plank upon which the Conservative Party then rested its opposition was that we Socialists were to interfere with the clinical freedom of the doctor. To them that was the biggest sin of all. The so-called principal technical ground was that there should not be the slightest hindrance in what the doctor wished to do on behalf of his patients and that he should not be denied the facilities that he thought he required in order to treat patients. I do not know whether the party really believed that but it thought the proposals abhorrent.

After the National Health Service came into operation all was well. In fact, it became accepted by the country at large. It was accepted even by the party opposite. I well remember the ringing utterance of the late Lord Butler—then Rab Butler. At the Conservative Party conference he said gleefully, "We are all Socialists now". They all rode in on the bandwaggon.

So why is there now the sudden urge to reform? Over the past 40 years the National Health Service has become admired worldwide. It has become admired as one of the most civilised institutions ever introduced in a democracy. Moreover, since we are talking about costs, and we shall again talk about them, it operates at a more economic cost than the United States, Canada or most other European countries. It takes between 5 and 6 per cent. of the GDP, whereas we all know that in other countries where the commercial principle is adopted, the cost is vastly higher than that.

Indeed, among the British people if there is one institution which is popular in the UK and commands real support and respect, it is the National Health Service. Of course there has been discontent with the health service. There have been complaints about waiting lists. Occasionally, of course, there are complaints about treatment. However, the principal item of complaint by the general population of the United Kingdom as regards the health service is underfunding.

This glossy booklet Working for Patients almost might have come from the noble Lord, Lord Young of Graffham. It might be well to bear in mind that the lack of public funds for the health service or certain aspects of it has cost human life over the past four or five years. There are numerous cases, which any medical practitioner will confirm, where a decision had to be made whether or not to treat a patient, or a choice had to be made between one patient and another because of lack of resources. The cases are numerous. There have been cases where those requiring renal dialysis have died because of the absence of kidney machines. They cost about £20,000 each and 50 machines would have prevented unnecessary deaths from renal dialysis. I am not a doctor. I do not know the techniques, but I know the results.

Lord Trafford

My Lords, it so happens that the noble Lord has chosen my own speciality. If he wishes to say that people have died because of the lack of kidney machines, which do not cost £20,000, I should like to know chapter and verse to which patients he refers and the places where they have died.

Lord Bruce of Donington

My Lords, I should be delighted to provide the noble Lord with that information. I have voluminous cuttings which list those matters over the years. I had not thought it wise to divert your Lordships with too much quotation this afternoon, but I shall see that the noble Lord is provided with that information.

This afternoon we are discussing the health and wellbeing of people. The prime concern of any government should surely be precisely that. We are all on the face of this earth for three score years and 10, four score years and 10 or sometimes more. We are merely transient. The pursuit of money for its own sake avails us nothing because we cannot take it with us anyway. However, the health and wellbeing of people is important and should be the first priority of all governments. Possibly people of our own age realise too often how important health is, particularly in old age.

We have to make a choice as a country: either we say that expenditure on health is to be subject to cash limits or we say that it is to be demand-led. The Government are not averse to demand-led expenditure. For the past 10 years they have acquiesced in complete demand-led expenditure in the common agricultural policy and other expenditure besides. They spent £2 or £3 billion on precisely that. Nobody says, least of all we on this side of the House, that because expenditure on a health service should be demand-led, there should be waste within it. Quite clearly, very serious attention should be given to those parts of the White Paper which are concerned with the elimination of waste and the establishment of efficiency. It would be silly to do anything other than that.

However, there is another ingredient. We know quite well that expenditure on the health service will grow because of advances in medical science. We know that it will grow because of the demographic structure of the older population. However, there are ways of limiting the costs of the National Health Service by not necessarily limiting the expenditure upon patients but by trying to limit the number of people who need it. That is where my right honourable friend Aneurin Bevan was so right in linking the policy with the broad general policies of government.

If there is a government committed to full employment, a government bent on the elimination of homelessness rather than increasing it, a government committed to building more houses in which people can live, a government bent on following social policies that promote the wellbeing and health of people and give them a purpose and an object in life rather than aimlessness, bearing in mind the connection between the mental health of people and their physical state, one then limits the use of the National Health Service. My old doctor used to say to me, "Always remember, the human body wants to be healthy if you will let it". There is profound truth in that.

The fact is, as the war years showed, that people with a purpose and with prospects for the future, with a settled perspective and a real meaning in life are, generally speaking, healthier than when they are left to rot and are treated badly. One Minister said last week that of course there was a shake out of labour as though labour were amorphous and not concerned with human individuals.

The noble Lord gave us an assurance that he respects the whole principle on which the National Health Service was founded: from each according to their ability, to each according to their need. That is an admirable socialist precept, but that is not shared by the Prime Minister. The noble Lord talked to the House this afternoon in dulcet tones and noble Lords elsewhere are quite prepared to trust the statement made in that regard. However, others do not.

In 1986 the Prime Minister, in an interview with the Financial Times, said quite clearly that she was committed to the elimination of socialism as a political force in the United Kingdom. Only three weeks ago she announced as her objective the elimination of socialism within Great Britain as a first aim. Of course; that is why the present National Health Service in its existing form, conforming to socialist principles, is a dagger pointed at Thatcherism itself. That is why, no matter what the noble Lord may say this afternoon and particularly in view of the provisions of the White Paper, if they are put into operation, there is nothing to stop the whole organisation being flogged off to private enterprise within two or three years. That is what we suspect, and that is what the population is afraid of.

We have a choice to make: whether the National Health Service should be demand-led, subject to proper safeguards, or whether the great professions of medicine, nursing, dentistry, ophthalmology, and all the ancillary jobs should operate as vocations—there is nothing dishonourable about a vocation— without the checks of accountants and such people, whose services in some respects may be necessary, and carry out their own jobs in their own way in the service of Britain.

5.30 p.m.

Lord Hayter

My Lords, despite the alluring title, Working for Patients, this is, to my mind, essentially a document about the management of the service. At this point I am already worried because changes in management are always fraught with danger.

When I was chairman of the King's Fund, to which my noble friend Lord Hunter made kind reference, I found myself dismayed, year after year, at the lack of management expertise in the medical profession as a whole. I do not say that in any nasty way because it was nobody's fault. The training of a doctor is sufficiently mixed up with his clinical training, and the rest of it, that he does not have the time to be taught anything about management. In fact, he will have to learn if this paper is to make any sense in the coming years. Whether that will pay off for the patients is, of course, the crucial question; but at this stage it is a question which is largely the subject of speculation and political rhetoric. Those of us who do not want to score debating points in such terms will just have to wait and see.

Before making three points about the management implications of the White Paper I first call your Lordships' attention to what is not in the White Paper. I am not referring to the elements that have already been discussed about dentists, and so on. The basic mission, values and funding methods of the National Health Service remain unchanged. The Secretary of State has expressly reconfirmed his own and the Government's commitment to them. Despite some of the proposals floated by the right-wing think tanks during the review, the fact is that the National Health Service is to remain a collective attempt to promote the nation's health and to provide services on the basis of need.

There seems to be some doubt about that expressed by noble Lords on this side of the House. However, I point out that not only has that commitment been made by the Prime Minister: it has also been made by the Leader of the House today. If by any chance they lied in their teeth in saying that and in the end the National Health Service were privatised, what glory that would be for their opponents. So do not worry about it, their opponents are bound to win both ways.

Noble Lords

It would be too late. The service would be dead.

Lord Hayter

My Lords, I now come to the management points. The White Paper makes two proposals to make something akin to a market. Major hospitals will be permitted to become self-sufficient, self-governing. Last week the figure was 320. This week it is 2,000. I am not sure what it will be next week—one must read the papers and listen to the Government on that point.

The hospitals will have considerably more flexibility than they have at present as to how they run their internal affairs. They will expect funding on the basis of the work that they do. That applies to hospitals. As regards general practice, the larger practices will be able to opt to hold budgets to pay for a range of routine services on behalf of their patients. Indeed, it is now apparent, according to the latest papers, that smaller practices can join together to do the same.

Both proposals are intended to provide incentives that do not exist at the moment for the institutions and individual practitioners. Of course, the general practitioners will need to become accustomed to budgets. I do not know whether they do so in their own homes but they will certainly need to do so in their practices. I hope that the noble Lord, Lord Bruce of Donington, will agree with me that a budget is telling the money where you want it to go rather than watching to see where it went. If they find themselves incapable of doing that themselves they will have to rely on accountants. Luckily, one of my sons follows the profession of the noble Lord, Lord Bruce of Donington, and he is therefore on to a good thing if he is needed by his local practitioners.

The second main point is that it strengthens the junction between clinical activity and management; for example, by increasing the number of hospitals that appoint doctors as budget holders and heads of clinical services and by tightening up the terms and conditions of those consultant appointments. Not only in medicine but in other professional fields—for example, consulting engineering and (dare I say it?) the law—the relationship between professional autonomy and the management of the enterprise as a whole is a thorny central question. Getting the balance right is never easy.

In essence, the proposals in the White Paper are sensible. The intention is to make the GPs and the hospital specialists more aware of the large resources that they are committing and to give them more management responsibility. That is fine, so long as they never allow professional excellence to take second place, as it sometimes does in East European systems, or allow the physicians' prime duty to individual patients to be obscured.

My third point is that the Government intend to shield the management of the National Health Service from detailed interference by the Department of Health and the regional health authorities. The new policy board chaired by the Secretary of State will determine what the Government want and the National Health Service management executive, chaired by the chief executive, will run the National Health Service within the broad guidelines given to it. We are told that the regional health authorities will be much slimmer and more streamlined than in the past so that the districts and the new self-governing hospitals can get on and manage with some confidence.

This combination of delegation with accountability sounds very necessary in such an enormous organisation as the National Health Service. It would have been more convincing if it had not been described in very similar terms in previous re-organisations, one after another, over the past 10 years or so; but let that pass, it needs to be done. Much will depend upon the Secretary of State's determination to run the National Health Service in a more sensible way than has been done in the past and on the strength of the understanding which exists between him and the chief executive. I suppose 1 would not be accused of telling an untruth if I said that the Secretary of State has a political role and that the real job of civil servants is to protect the Minister and the Government. Neither of them should be getting mixed up with the National Health Service in its intimate details.

Therefore, while the intentions behind these proposals seem to be admirable, we must see how they work out in practice. However, there are real dangers in such radical changes. Here I get back to the point which has been mentioned once or twice in the debate. The National Health Service is likely to become much more expensive and the added spending may not prove to give equivalent value. Some general practitioners may try to economise to their own profit. Some hospitals may be tempted to do work that is not of high priority in terms of need simply because they will be paid for it, and so on.

As I said earlier, those of us who are not politically oriented simply cannot know in advance or pretend to know whether the White Paper proposals in practice will or will not improve the National Health Service. In that sense the White Paper's title is, to put it politely, no more than wishful thinking. But the proposals seem worth a try provided the Government are prepared to modify and adapt the rules in the light of experience. That is an essential management principle. I have known it in my business, and people who have been in business know that if one is changing management there will be problems but one must be able to back it up financially. Like so many matters of management, it is a question of common sense.

The reason why the National Health Service has been constantly re-examined and reorganised in the past 15 years—a matter raised earlier by one or two noble Lords is not that it is inefficient. Compared with most other health care services in the world it continues to offer very good value for money. But medicine develops faster than our collective willingness to pay for it. I am sorry that he is not here tonight, but a long time ago when I was in New Zealand I met the noble Lord, Lord Porritt, who was a famous doctor. He told me something that has stuck in my mind ever since. He said that there is no country in the world that can afford the national health service that it wants. That goes for us as well as for anybody else. As I have said, medicine develops much faster than our collective willingness to pay for it. It is a problem that has occurred elsewhere as well. There are continuous difficulties within the National Health Service of trying to develop new services and to maintain the old ones.

The White Paper seeks to improve the ways in which this extremely complex management task is tackled without giving up the fundamental aims of what is still, for all its faults, a great British achievement for which your Lordships and I, as we grow older, will have every reason to be grateful. The principal of good management is in education. I have one question to ask the noble Lord who will be replying and that is whether he will agree with me that part of the education, particularly of those of the medical profession, will have to include some of these principles of management? It seems to be quite essential.

I hope that the message that is to be given by this House to the nation will not be about the weaknesses of the White Paper—Heaven knows there are many!—but will give encouragement to use the opportunities that it offers without sacrificing what is good in the National Health Service. I hope that we shall also keep a very close eye on what actually happens so that we can judge the effects rather than the intentions.

5.42 p.m.

Baroness Cox

My Lords, I join with other noble Lords in thanking the noble Lord, Lord Hunter of Newington, for initiating this debate. I greatly regret that I have a long-standing commitment to host a dinner this evening and I shall have to leave by 7 o'clock. But I shall read the rest of the debate with very great interest.

I welcome this opportunity to begin discussions of the White Paper because the issues are so crucial that it is vital for the country and for the Government to get them right. In the foreword to the White Paper, my right honourable friend the Prime Minister states that: The National Health Service will continue to be available to all, regardless of income, and to be financed mainly out of general taxation.". She concludes with these words: The patient's needs will also be paramount.". These commitments which were reaffirmed by my noble friend the Leader of the House this afternoon are warmly welcomed. They embody two of the principles on which the National Health Service was founded. Like my noble friend Lord Trafford, I am one who has always been an ardent supporter of the National Health Service and I am therefore very relieved to see that the Government are endorsing and reaffirming these fundamental principles. The Government have also demonstrated their real commitment to the National Health Service by the dramatic real rise in expenditure in recent years. It is true that we still spend relatively less of our GDP on health than other comparable nations and there will be a need for further increases in funding to meet increasing costs of health care to meet increasing health needs.

I also welcome the fact that the principle of accountability to the patient is being recognised in various ways: for example, by recommendations that appropriate information be given to patients in hospital and that provision should be made for channels for suggestions and/or complaints. I particularly welcome the commitment to retain community health councils. I also welcome the devolution of power and decision-making with district health authorities whose membership will be streamlined, comprising those with direct responsibility for the provision of care. So far, so very good. Like the noble Lord, Lord Hayter, when I recollect how the Government have resisted considerable pressure from many sources to adopt a more American-style model of a health system based on private insurance, I can say on this matter wholeheartedly, "For this relief, much thanks".

However, I have some serious concerns that I hope will be addressed during the consultation period. First, the White Paper seems to have lost the important concept of a seamless web of a total health service. It is overwhelmingly oriented to a medical service and it virtually ignores the need for an integrated system of community care. As the noble Lord, Lord Winstanley, indicated, this is a very important point. If a dichotomy between hospital and community care is allowed to develop there is a danger that we may revert to the unsatisfactory fragmentation that existed prior to 1974. One serious problem of such fragmentation will be the tendency for resources to be channeled into areas of acute need and for patients with long-term and chronic problems to be relatively neglected.

Nobody wants the care of the mentally ill or handicapped, the chronic sick or the elderly to become Cinderella services once again. So I hope that it is not a disturbing portent that the White Paper concentrates so exclusively on the medical services in general and on the hospital services in particular. Secondly, there is widespread concern over the allocation of the responsibility for community care. I shall not repeat the points that I made in the recent debate on the care of the elderly in the community except to re-emphasise that many health professionals believe that the primary responsibility for the growing number of vulnerable people in the community should reside under the general aegis of health authorities and health professionals rather than local authorities and social workers.

I intend no disrespect to social workers, but they lack the clinical training and experience needed to provide adequate care for many of the mentally ill, mentally and physically handicapped and infirm-elderly living in the community. While some local authorities provide excellent standards of care others have shown themselves lamentably incapable of so doing. I suggest that we cannot afford such variation in the provision of care for people who are inherently vulnerable. I hope passionately that the Government will not accept that recommendation in the Griffiths Report on community care.

Thirdly, I hope that the Government will consider setting up an inspectorate like Her Majesty's Inspectors of Schools, to monitor standards of care throughout the National Health Service including residential care—even small-scale provision of up to three-bedded homes which are at present immune from any kind of inspection. Such monitoring is urgently needed. Anyone who works in the health area knows the utterly unsatisfactory situation in some homes where, for example, as soon as you enter, your eyes water with the acrid smell of urine from patients who are incontinent and inadequately cared for. These appalling conditions must be addressed as a matter of urgency if the Government are to show that they really are "Working for Patients".

Fourthly, there is widespread concern about budgeting. In a sense every patient will have a price tag. Reassurance needs to be given that this will not in any way impede their access to appropriate care. Is there no danger that budget-conscious GPs might be reluctant to take on expensive and/or long-term treatment for patients who may make heavy financial demands? Is there no danger that opted-out hospitals might be reluctant to accept low income-generating patients, such as the long-stay elderly? Might there be pressure to discharge some patients into the community prematurely? Can my noble friend give reassurance on these matters which are causing many in the health professions great anxiety?

A more general point arises. I seem to recollect a third founding principle at the inception of the NHS: equality of access to health care. There is widespread concern about the possible danger that proposals might allow for the development of a new two-tier system. This fear has been expressed by my colleagues in the Royal College of Nursing. For example, might not hospitals which opt out of DHA control be better placed to raise money and take initiatives which will put them at an advantage relative to hospitals still within the district health authority? I give as an example the freedom to determine terms and conditions of service for their staff. Is there a possible danger that quality of care might in some cases be judged ultimately by the financial criteria of the bank manager rather than by ultimate consideration of the best possible care for each and every person in need?

I should like to refer to two matters specific to nursing. I warmly welcome the proposal to ease the excessive pressures on junior hospital doctors. I welcome not only the appointment of 100 more consultants but also the extension of the responsibilities of nurses. The increase in the responsibilities of nurses will be cost effective in that it will make good use of trained professional staff and increase job satisfaction. These were points mentioned by the noble Lord, Lord Hunter. It will also relieve the excessive workload of junior doctors and enable them to offer better patient care.

However, this extension of the role of the nurse raises a question about nurse education. The Government are to be applauded for their agreement in principle to the reform of nurse education through Project 2000. Student nurses will have more time to study, to learn the why behind the how and to be relieved of much of the stress of trying to combine academic work with long periods of demanding clinical practice. 1 welcome also the expected announcement of a number of demonstration projects.

The profession is anxiously awaiting the go-ahead for full scale implementation of Project 2000. I wonder whether my noble friend can give any reassurance for until this is forthcoming the profession is left in a state of limbo which hampers necessary adjustment and is detrimental to nurse education at a time when nursing faces real problems in trying to attract and retain students. The National Health Service will need all the nurses it can get if it is to be effectively "working for patients".

I conclude by saying how much I welcome the opportunity to highlight some issues which must be considered carefully during the consultation period. I hope that all who are actually working for and with patients will also make their views known, based on their experience and their commitment to the highest possible standards of care. I hope too that the Government will listen and learn from them. I hope that they will heed their advice so that as a nation we may continue to develop a National Health Service which, as I have said and as I will continue to say, is one of the most humanitarian institutions the world has ever known.

5.54 p.m.

Baroness Seear

My Lords, like my noble friend Lord Winstanley, I am astonished that a review of this kind excludes any reference to community care. The noble Baroness, Lady Cox, has also referred to this point. I am not only surprised; I am genuinely alarmed. It seems to indicate that the Government, as shown also by their long delay in reacting to the Griffiths Report, are simply not aware of the seriousness of the problems involved in community care. It seems that once again the Government and the department are unaware of what is going on elsewhere. The decisions being taken in regard to housing benefit are increasing the difficulties of people trying to cope with the elderly and the infirm.

As a result of the Government's policy of getting people out of institutions and back into the community, a policy which if it were properly implemented we would support, great difficulties are being caused. The Government do not seem to be aware of the horrors building up in the face of what is needed to deal with the old, the infirm and people coming out of mental hospitals and other hospitals to be looked after, as it is euphemistically said, in the community.

Have the Government taken on board what those who run hostels for people with special needs are saying about decisions being made under the Housing Act? It has been pointed out to them often enough. Those running the hostels are saying seriously—not hysterically, but as a result of sober calculation—that they will not be able to keep the hostels open. What does this mean? It means that as people come out of hospital requiring special housing of some kind it will be increasingly difficult for them to get it. In the past few months I have heard this repeatedly from associations with which I am connected. It means that the whole question raised by Griffiths is of the highest importance.

I wonder whether the Government have really taken on board what is involved in looking after people in the community. Unless much better provision is made on a community basis, the families of these people will have to attempt to cope somehow or other. We are told on the best calculations that some 6 million people look after the aged and the infirm in their own households, most of them doing so single-handed. Illness, infirmity and old age do not distinguish between class and party.

There can be few noble Lords who have not had in their own families some experience of what is involved. Anyone who has attempted for any time to look after people in this condition will know what is involved. They have to get out of bed night after night, three, four or five times. This makes life impossible, and it cannot be continued unless adequate help is given. Yet that is what the accumulation of bringing people out of institutions, cutting back on provision in hostels and at the same time not providing the services that are required in the community means. This is not a short-term measure. It is a matter of great urgency.

The Griffiths Report was published more than 18 months ago. The noble Lord, Lord Hesketh, who is to reply tonight, has said twice recently that we shall have a response very soon. I live in the hope that perhaps tonight will be the night when he will tell us; but I gravely doubt whether that will be the case. It cannot be left any longer or there will be a real disaster. If the families cannot cope—I assure the House that after a period they cannot cope—where will these people be? The hostels cannot take them, the families cannot cope and they are out of the institutions. Where will they live? In cardboard boxes? That is really what we are saying when we refuse to follow through the recommendations of the Griffiths Report and all the other policies.

I do not believe for a moment that the Government want this to happen. I beg them to treat it as a matter of the greatest urgency. Up to a point I agree with, support and amplify what was said by the noble Baroness, Lady Cox. However, I do not agree with her on where the responsibility should lie. I do not agree mainly because this must not be seen solely as a health matter, although it should be treated in the context of the recommendations. It is partly a health matter but one must look at the needs of the whole caring unit—the family.

Very often a single person on his or her own is looking after an elderly person. These people need a whole variety of services which are not health services as such; they are ancillary and extra services, but they are very important. In my view such services are best co-ordinated, as Griffiths recommended, through the social services department, handled by social workers working closely with the health services. That is why such provision should be a very prominent feature of the review and not something which is totally excluded.

6 p.m.

Lord Dainton

My Lords, I am conscious of the fact that at this hour mine is the twelfth only of 29 scheduled speeches. That gives great force to the old Latin tag, bis dat qui cito dat—he who gives quickly gives twice. Therefore I intend to concentrate solely on one major issue. The title of the White Paper Working for Patients expresses an extremely laudable sentiment about those patients who the Government claim are their main motivation in proposing changes to the National Health Service. What is certain is that the proposed changes will be judged by the extent to which they are perceived by those who receive them as improving the care of patients.

There are two kinds of patients to be considered—those being treated now, and those who will be treated in the years to come. In both cases the quality of treatment received will be crucially dependent upon the standard of the long undergraduate and postgraduate training of the doctors who diagnose the disease and prescribe the remedies.

Hospitals in which undergraduate and postgraduate teaching and research are carried out—in some, it is both—are very special places. It is there that the needs of the present confront those of the future. Today's patients must be cared for. However, to ensure that the care of future patients is satisfactory, today's students—who will be tomorrow's registrars, consultants or general practitioners—must be educated in the best possible way. Their teachers range from, at one end of the spectrum, whole-time academics on the staff of the university medical school whose offices and laboratories are physically embedded in the hospital and who, as honorary consultants or registrars, have care of patients to, at the other end, NHS staff who hold honorary academic posts by virtue of their contributions to teaching.

Striking the right balance between the demands of the present and those of the future has never been easy, as I know from my experience nearly a quarter of a century ago when starting the first new medical school to be established in this country since 1893; then from my time at the University Grants Committee; and finally-here, I have to declare an interest—as chairman of the Royal Postgraduate Medical School.

Under the existing National Health Service structure, the composition of the kind of district health authority which has hospitals with teaching responsibilities in its care has never adequately reflected the importance of the teaching and clinical research roles of those hospitals. Nor does the White Paper, as the noble Lord, Lord Flowers, mentioned, really pay due regard to that point.

However, the White Paper shows that the Government are not afraid to think radically. Might they even consider, as I hope they will in their further considerations, that at least some teaching hospitals have a unified system of government and administration in which those two elements of patient care now, and teaching and research for the future, are brought more closely together? The opportunity to think afresh on this important matter will not, I suggest, recur for many years; therefore, it should not be missed.

At the same time it is important that the principles of resource allocation should be subject to critical scrutiny. Here, I should like to make just two points. First, it seems clear from the White Paper that the income of a hospital will bear some direct relationship to its "output"; that is to say, the amount of work done. Indeed, the noble Lord, Lord Belstead, confirmed this in his remarks. That seems to me quite reasonable as a principle. But, if the work done in teaching hospitals is measured solely by patients treated, it would create very great pressure on all those clinicians, who also have teaching and research responsibilities, to diminish the time and energy they give to their teaching and research. Some means must be found to avoid that situation; otherwise, the quality of care given by the whole profession is bound to undergo a steady decline.

Secondly, it is all too often forgotten in allocating resources—although it has been mentioned today▀×that the SIFT formula (the service increment for teaching) does not recognise research per se. Moreover, if income is related to patient throughput, as we have been told that it will, then it must never be forgotten that research inevitably reduces that throughput quite significantly because patients undergo more prolonged investigation. More laboratory tests are required and more consultations with doctors are necessary. Further, more research seminars, and all the aspects which go with good research, will erode the time available for treating other patients.

I hope that I have convinced your Lordships, and the Government, that much more thought needs to be given to education and research in the National Health Service than appears to be the case in the publication of the White Paper. Further, I hope that Mr. France's inter-departmental working party, which is referred to in the paper, will do just that and not be afraid, as I said earlier, to be quite radical.

Perhaps I may add that the matter seems to me to be so important that I consider it essential that the new National Health Policy Board, which has not been mentioned today but which stands right at the top of the Department of Health, should keep the matter constantly under review. To do that effectively, it appears to me to be essential that it should include in its membership someone who is very knowledgeable and experienced in this particular field. Otherwise, I feel that the issue, and the consequences of it, will go by default.

6.8 p.m.

Lord Tranmire

My Lords, I too am grateful to the noble Lord, Lord Hunter of Newington, for giving me the opportunity first—although I did not expect it—to listen to the recollections of the noble Lord, Lord Bruce of Donington, going back some 40 years, and, secondly as the oldest surviving Minister of Health in the country, to offer my congratulations to the youngest Minister who has just taken over the post and who has produced this large library of documents through which we have been looking.

I do not wish at this hour to waste much time. However, I should like to make two points. First, in looking at this problem—which concerns all of us—of how to get the necessary resources into the health ministry, one has to realise that all the countries in Western Europe normally base the cost of their health services on compulsory insurance; whereas we rely on the general exchequer. The effect of that reliance is that the countries of Western Europe, except ourselves, Denmark and Ireland, all spend roughly 8 per cent. of the GDP on health services. This country, Denmark and Ireland spend only about 5.5 per cent. to 6 per cent. There is a clear division. It shows the degree to which central control has, over the past 40 years, diminished the availability of cash resources for the National Health Service.

I welcome the Government's new way of dealing with those matters by the formation of self-governing hospital trusts. That may be a way of putting more money into the NHS. There are some problems with that which have not been entirely covered even in Working Paper 1. If someone in Yorkshire has a place in a hospital trust in London, he will require accommodation not just in the acute section of the hospital but in the community section if he needs a long stay or is convalescing. How will that work? If it is not covered, such a patient will not be able to take up that place.

What is equally worrying is how the general practitioner will be dealt with. Those who qualify for the general practice budget are all right provided that they are trained as accountants. That will be necessary in future. Will those whose numbers are below 11,000 lose by being unable to qualify for the practice budget system? I hope that the Minister will deal with that point either in his reply or by correspondence.

It is a bold plan. It is necessary. There has been some complaint because the working paper deals mostly with acute hospitals. From what the BMA tells me, the review originated when the Central Committee for Medical Services complained about the alarming and serious shortage of cash in acute hospitals. For that reason, the review concentrated on the acute side. To be complete, the community side must be dealt with and I feel sure that it will be. This is a good beginning for our new Minister for Health. I wish him all good luck.

6.13 p.m.

Lord Carter

My Lords, like other speakers, I wish to begin by thanking the noble Lord, Lord Hunter, for putting down the Motion and giving us the chance to discuss this important subject. We were told to expect fundamental review and have received a complex presentation of the White Paper and eight working papers. The review poses more questions than it answers.

I heard the "Jimmy Young Show" a few days ago on the car radio. The Secretary of State for Health, Mr. Clarke, was answering questions on the show about the review. I believe that we would all agree that a chat show on Radio 2 is the one place where one might expect a simple explanation. I am interested in the subject and must admit that I was thoroughly confused by Mr. Clarke's answers.

The Government have responded to a real crisis in the NHS—a crisis created largely by under-funding. Their response may be a massive political misjudgment. As my noble friend Lord Ennals said, it may also turn out to be a fatal electoral misjudgment.

The working papers were produced in something of a rush. There was not even time to leak them. From reading the White Paper and the working papers, one gains the overwhelming impression of a trade in patients conducted in an administrative and accounting maze.

The noble Lord, Lord Winstanley, referred to the problems of accounting. I have had over 30 years experience of management accounting. Whatever industry one is in, management accounts depend upon pretty arbitrary assumptions and conventions: the allocation of overhead costs and fixed costs, and the social costs mentioned by the noble Lord, Lord Winstanley. Doctors should be wary of the spurious authenticity of all-singing, all-dancing computer programmes which purport to discover the cost of medical treatment. The answer will depend entirely upon the assumptions which are built into the programmes in the first place.

To make sense of the complexities of the documents, I tried to relate them to three health service matters with which I am familiar and involved. The first is the case of an elderly relative who was recently admitted to hospital after a stroke. How will the review affect people in her condition? The second relates to a family with two handicapped children, and the third is the impending reorganisation of a local hospital service.

I shall take the geriatric service first. As your Lordships will be aware, considerable worry about the White Paper has been expressed by a number of organisations connected with the care of the elderly. Age Concern is unhappy about it. The British Geriatrics Society, which represents 1,500 geriatricians with a special interest in the management of illness and old age, says that the review and the White Paper offer no prospects of improving services for the elderly. In fact, it condemns the review as naive and piecemeal. It claims that opted-out hospitals will be likely to disassociate themselves from geriatric and psychiatric services; and because of the problems related to travelling long distances, frail elderly people will be unable to benefit from the internal market.

My elderly relative and others in her condition will not find much comfort in that opinion. I shall be interested to hear the Minister's response to that view which has been expressed by other speakers.

I shall now take the case of the family with two handicapped children. The son, now a young man, is chronically ill, and requires a number of visits to the hospital. Working Paper 3 at paragraph 3.4 sets out the position extremely well: In many cases, when the GP refers a patient to hospital, he will be confident of diagnosis, the likely subsequent treatment, and whether this is likely to be a call upon his practice budget. Treatments which are a charge to the budget will generally be 'elective' and GPs will indicate to the hospital their requirement concerning the timing of treatment. The cost per patient will normally be fixed in advance and will reflect the hospital's assessment of the likelihood of complications in some cases and their cost, in relation to any particular treatment. The hospital bears the cost (or reaps the benefit) if the outcome differs from this assessment". That is all very smooth and efficient and gives the firm impression of a seamless bureaucratic robe. What happens to that young man in practice? Let us take a typical phase in his illness, not an emergency. He is referred by the GP to the district hospital. He spends a few days there. He is then moved to the regional hospital for specialised treatment. He is then discharged into the care of the GP again. His parents take him to Great Ormond Street for a second opinion. He returns again to the GP and has a succession of visits as an out-patient and an inpatient to the district hospital, the regional hospital and two hospitals in London for different conditions. That is a true example. How is all that to be accounted for? It could well be a case where £5,000 annual costs to the GP budget, which was mentioned in a working paper, will be exceeded, but it all has to be accounted for to discover whether the treatment has cost more than £5,000 or not.

A third example, in attempting to relate the White Paper to reality, concerns the fundamental reorganisation of a local hospital service. It happens to be going on in the town in Wiltshire where I live, but there must be many other towns in the same situation. This is a point which I have not yet heard raised in the debate or in any other discussions on the White Paper. The strategy of the district health authority is set out in a very good consultative document. The document says that the strategy is based on the needs of each community matched against the resources likely to be available over the next 10 years. Costs of rebuilding and refurbishment have to be met largely from the authority's own land sales. Similarly revenue costs of substantial improvements in community care can only come from reductions in local hospital expenditure.

In practice, the proposal is to reduce the number of local hospital beds from 106 to 41; to end surgery under anaesthetic in the local hospital; to build a new community hospital of 41 beds, using the proceeds of the sale of the sites of two existing hospitals—a cottage hospital and a long stay geriatric hospital; and to close the local pathology lab. That lab was able to identify within two days the salmonella poisoning from which I suffered last May whereas I am told that the district path lab would have taken a week.

The hospital with 41 beds which I mentioned will have to cope with the requirements of general practitioners and short stay geriatric treatment as well as operations under local anaesthetics. There is intended to be much greater reliance on the district hospital. This is much harder to get to. It is impossible to park when one gets there and because of the lack of rural transport it is often impossible to get to a clinic and back in the same day if one does not have a car.

There has of course been very great local concern about this. Some very hard work has gone on in the local community into a response which has been prepared. It concludes: The Steering Group has not been able to assess the potential impact upon the Consultation Document, of the recent Government paper entitled Working for Patients, nor the impact of such reports as the Griffiths Report. On the face of things however there are clear implications in both the paper and the report for the consultation document.

What happens now if the district hospital decides to become self-governing? Can the Minister tell the House what happens to those reorganisation plans which are being considered now? Decisions are to be taken, I understand, by the district health authority within the next two months. As a result of the White Paper should not these plans all now be put on ice until the district hospital has decided on its status in the future? The relationship between the district hospital and the local community hospitals in its area is a crucially important part of the plans for reorganisation.

There could be another reason for postponing decisions on these plans. Working Paper 1 sets it out well: All hospitals are potentially eligible for self-governing status. There will be no rigid definition of what a hospital should be for the purposes of self-government. Neighbouring hospitals with complementary services may want to combine into a single management unit where this is consistent with maximising the choice for patients and GPs. The Government will therefore encourage as many hospitals as are willing and able to do so to seek self-governing status.

Supposing the local hospital which is facing reorganisation now decides that it wants to team up with other community hospitals in the surrounding area, to share services and to combine in a single management unit, and to contract with the district hospital or other district hospitals and regional hospitals for the specialised services it needs.

Can the Minister tell the House how that sort of decision is affected by the White Paper? Decisions on the reorganisation plans are to be taken in the next few months. Surely all these plans should now be put on ice, as I said, until we know how the district and local hospitals wish to react to the White Paper.

I have given just three examples to illustrate the confusion that I think exists as a result of this review. I could quote many more if time allowed. The Government must now give time for proper consideration of the White Paper. That is a point that was made by the noble Lord, Lord Hunter, when he opened the debate and by many other noble Lords. The examples I have given show that more time is required in which to work out the practical, on-the-ground implications of the White Paper.

I think that the Government may have missed a great opportunity. Both the Government and users of the health service, as well as those who work in it, now face a period of confusion and uncertainty which can do nothing to improve the health of the nation. Perhaps the greatest irony of all is that they may end up by creating an irresistible demand for more resources for the health service.

6.26 p.m.

Lord Seebohm

My Lords, at this stage of the debate most of the points which I planned to make have already been made so I shall be brief. Personally, I have no particularly close knowledge of the NHS so I propose to make my remarks from the point of view of the personal social services about which I know a little.

I welcome the managerial approach of the White Paper. It is very important and by no means new to the personal social services—we have gone quite a long way in that regard. However, what worries me is that in reading the White Paper I can find no reference whatever to the personal social services or to any other of the services, apart from the National Health Service. That applies also to the eight working papers. I admit that I have not read right through all of them but I cannot find any reference in them to the personal social services.

We are about to receive a report on the Griffiths Report; some commentary has been promised within about a month from now. I hope that the report will not be later than that but it should have come out a long time before the White Paper. These matters cannot be separated. If the comment had come before the White Paper we should be talking a lot more sense tonight. It is obviously important to restate the absolute interpendence of the two services in that neither can function effectively without the other. I wish to confine my comments to two main issues: first, the elderly who have already been mentioned by many noble Lords and, secondly, community care. In this regard I re-echo a great deal that the noble Baroness, Lady Cox, said which I thought was very useful indeed. It is well known, for instance, that the proportion of elderly people in the population is increasing rapidly and that something like 50 per cent. of all the visits made by doctors are home visits. As the proportion increases, the capitation fee will need to be regularly recalculated if the elderly are not to be looked upon as a financial burden and in consequence given less attention than they require.

There does not appear to be anything in the proposals for GP budgets to cater for the rising demand to move the elderly to hospital for their community care, psychiatric care, nursing provision and all the various other requirements of the elderly users. I suppose that we must wait for a further paper on how community care for the mentally ill and the mentally and physically handicapped is to be managed and on whose budget it will depend. In this field the social and health services are absolutely indivisible. What I am really getting at is that by looking at the services piecemeal we may find ourselves with only partial solutions, leaving unsolved the question of where primary responsibility and accountability lie.

Finally, I wish to say something about general practice. I note that to start with the new budgeting scheme will only be available to practices with 11,000 patients, which I take to mean with about five general practitioners. I am a great believer that where possible all practices should be of that size or greater and should include the services of adequate secretarial staff which will be needed very much more now that we are to have budgets; and at least one health visitor.

It is absolutely essential to have a social worker, the regular attendance of a chiropodist and also a dispensary. All those seem to be necessary for an effective general practice service. The link with the social work services is essential. Placing a social worker in the general practice centre will mean that many of the blocks caused by principles of confidentiality will disappear and, as I said at the beginning, a far more complete service can be provided to the user. If I had time I could provide examples from the report that we produced 20 years ago which show how absolutely essential those services are and how many doctors said they had patients who needed social care but who were never reported as needing that care.

More thought must be given to the composition of the lay membership of RHAs, DHAs and FPCs. There must be someone from the social services on all those committees. That is absolutely essential if we are to have an effective service for everyone. I conclude by saying that while I welcome parts of the White Paper, I hope that the relationship with the personal social services will be given a great deal more thought.

6.30 p.m.

Baroness Gardner of Parkes

My Lords, I am pleased that this debate has suddenly speeded up a little as I am speaking at a dinner and I must unfortunately leave within a certain time. I had thought the debate was going so slowly that I would not have the opportunity to say anything. After 30 years in the National Health Service I would have been very disappointed if that had happened.

Although I have spent 30 years in the National Health Service, it is only in the past 10 years that I have occupied a position as a non-executive director on boards of various businesses. That has shown me that there is a need for people who handle budgets or who are responsible for quite high expenditure to have a bit of an understanding of how business principles work. The White Paper brings in a very healthy aspect—it makes people appreciate the concept of value for money. I look on those words as being good words. I heard them used in a less flattering way earlier in this debate. But I think it is good to get value for money.

The noble Lord, Lord Hunter of Newington, who was such a help in introducing this debate, made the point that there was nothing about dentistry in the White Paper. That is true. However, one aspect of dentistry that is relevant to this debate is that it has excellent quality control. Quality control will be an important element in these new proposals for the health service as regards obtaining value for money. It will be important to have someone monitoring the proposals to see how satisfactory the results are. I have been involved in many reorganisations in the health service. Each time we were told things would be better, but each time they were worse.

I have great hopes for this reorganisation. Any woman who reaches her fortieth birthday considers herself middle-aged and looks for an uplift. The health service, being 40 years old, is also in need of an uplift. The proposals before us now may produce that. In 1974 area health authorities were created. Since that date I have had the privilege of serving on the board of what was a retained board of governors at the Brompton national heart hospital. A special health authority has recently been created there. Hospitals were all lumped together into area health authorities and then later into district health authorities. But that hospital has carried on in the old way. I served on an area health authority for many years before that system was abolished and the system of district health authorities was set up.

I think that individual hospitals work the most efficiently. They are the closest thing to what the new system will try to set up. People controlling such a hospital can take a direct and personal interest in what is going on within the hospital. In the case of the particular hospital I mentioned, a marvellous new building is being built. That must be of benefit to patients-not only to patients from all over this country, but to patients from Europe. We believe it will be the best heart hospital in the whole of Europe.

We have talked about the interlinking of the National Health Service and private medicine as if it were something new. But the hospital I mentioned has for years been working with the Cromwell—that is a well known private hospital—in terms of training nurses in specialist care and intensive care. Various training schemes have taken place which neither of those two hospitals could have provided individually. The hospitals worked together to provide training schemes for nurses. That system worked very well.

To label the private sector as all bad is not the right answer. Concern has been expressed about private health insurance. I encourage people to take out private health insurance because I believe that anyone who removes a financial burden from the state helps to make more of the state's money available for others. That is the opposite side of the argument that was mentioned earlier. However, my concern with private insurance is that private insurance schemes may only be willing to accept people when they are healthy and will dump them when they are not. It is totally unacceptable that private health schemes should be able to dump unhealthy people back on to the National Health Service.

The Government must look at what they can do to ensure that people who are in a private health scheme are not suddenly thrown back on to the National Health Service. However, I am a great believer in the theory that people should be entitled to spend their money where they wish and it is up to them whether they spend their money on health care or on holidays.

The noble Lord, Lord Ennals, said that the White Paper's proposals put producers before patients. If I thought that I would not support it. But I believe that the basis on which the proposals have been developed is that of the patient being the foremost interest. Working in the health service for so many years has made me aware that we are all a bit like farmers; nothing is ever quite right. Everyone in the health service believes there is something wrong and that improvements could be made. Farmers would even like to see the weather fixed for them. Similarly people involved in the health service want to see everything perfect. We all have an idea of how we would like to see the health service run. The health service as it exists at present is not right; we would be deluding ourselves if we thought it was. There are now great gaps in the health service. There is also great dissatisfaction with the service. An opportunity must be available to look at ways of improving it. I am very hopeful that the White Paper will provide the means to improve it.

A Labour government brought in the RAWP scheme. That chopped back money for London in particular. I thought the terms of that scheme were terribly hard for London. But as time has gone on the formula has changed slightly. In some areas there has been greater population growth than in others. So one cannot dismiss the terms of the scheme completely.

The situation in pharmacy has not been mentioned. Nevertheless that is an important service. I disagree with only one issue mentioned by the noble Lord, Lord Seebohm—the issue of dispensaries. I am all for the kind of general practice that he suggested, but I am not convinced that such practices need a dispensary. Perhaps in a rural area there may be a need for a dispensary but in cities where there are plenty of pharmacies, to have a dispensary in a practice would be duplicating costs.

As regards the size of practices, the practices that I have seen in London, and which are set up on a larger scale, provide first-class medical treatment. I mention in particular the Lisson Grove health centre. There are two practices there which are associated with St. Mary's Hospital. They provide a marvellous service. However, in the Knightsbridge and South Kensington area, it is extremely difficult to get on to any general practitioner's list. Those practitioners are only national health practitioners in name. If a patient gives them an address which sounds as if it is in an expensive area, they do not want to accept him as a national health patient. They only want to accept such a patient as a private patient. However, if a patient can convince them that he is working for someone who lives at the address given, he might be accepted as a national health patient.

There is a real problem in London now where National Health Service practices exist in name only. They are not really available to National Health Service patients. Something must be done to ensure that that situation does not continue. I was pleased to hear the statement made that patients would take the money with them. That statement has not been spelt out, but I think that idea is a very good thing. I have always been involved in hospitals where patients have come in from all parts of the country. The money has come out of our pocket and there has been no way of claiming back a penny from the area which has referred that patient. I take a system in which the patient will take the money with him to mean that everywhere one goes the treatment to which one will be entitled goes too.

I hope that that principle will be extended a stage further to the point to which the noble Lord, Lord Seebohm, referred. I hope that the money will go with one whether one has treatment in hospital or in the community. For as long as I can remember successive governments have thrown more and more responsibility on to local government without giving them the money to match that responsibility. If the money is allocated for the patient a premium might apply for elderly patients, who would need more of the doctor's time, so that doctors would be more willing to accept them. In hospital they would be able to receive treatment, and in the community they would be able to receive treatment. I think that that would work very well. I hope that a system of that kind will be taken into account.

The General Dental Council recently produced a leaflet which was intended to be of help to elderly patients and to those caring for them. As dentists, we prepared in conjuction with other experts a leaflet which we thought would appeal to elderly people and he extremely useful. We set up clinical trials to find out what people thought of it. We were stunned when the answer came back that it was absolutely useless and strongly disliked. That demonstrated to us the need to assess schemes that one intends to set up for patients which, on paper, appear to be marvellous. One needs to discover the patients' reaction and to find out whether the system works as one thought it would.

I strongly support the idea of change in the health service. I believe that there is a need for change and that this is the time for change. I believe that there are many issues which must be thought through and this debate has brought out many points of great relevance. It will all be on record in Hansard and can be carefully considered by the department. In principle, I support the proposals.

6.43 p.m.

Lord Brain

My Lords, as the evening is progressing I too shall attempt to cut short my speech. I shall follow a number of the points made by the noble Lord, Lord Flowers, and the noble Lord, Lord Dainton, and deal principally with the aspects of the White Paper relating to junior hospital doctors and some of the problems which may arise.

New NHS hospital trusts are proposed. The White Paper says that they will be free to do what they like in respect of conditions of employment for junior hospital doctors, subject to certain approvals by the Royal Colleges. On the one hand the trusts are expected to follow Government policy but they are also free to determine their own conditions of service. I can foresee that situation giving rise to problems for junior hospital doctors who are looking to the next step in their training. It is fine if they are going on to a specific two-year training course. However, not all of them want to do that; they want to shop around, to cover particular specialties, to work with a particular team and so on.

That is not very difficult now because they know that standard NHS terms will apply with rotas of one-in-three, one-in-four or one-in-two, with other bits and pieces. Will they have to go to the computer to find out what specific terms of service, conditions of employment or peculiar rotas apply at the various NHS hospital trusts? Think of the problem facing the Royal Colleges if they have to go round 300, or 2,000, different hospitals to vet the training they have set up for their junior hospital doctors and approve those posts. That is a problem. I do not say that it is an insoluble problem, but it is one which has to be recognised and looked at in the discussion.

The White Paper also comments on training and research. I think that the issue was neatly ducked, because the White Paper includes a little about SIFT, apparently in the hope that we should not probe too deeply. However, the working papers make it clear that at the moment SIFT applies only to teaching hospitals. These are undergraduate teaching hospitals. But all hospitals are teaching hospitals because all junior hospital doctor posts are training posts. The funding of that level of training and the allowance for proper training and teaching is a vital matter.

It is essential to make sure that doctors have an opportunity to study in addition to the training they receive in the course of their medical treatment of patients. They may be seeking membership of one of the colleges, or taking diplomas in gynaecology or obstetrics, and so on. They may be working a one-in-three rota and barely have time to study during their normal free time. They need study leave. In many cases they can be allowed study leave only by changing the rota from one-in-three to one-in-two.

There is also the problem that certain hospitals which are considering the new trust status are not even considering such study leave. I know one hospital not very far from here where there are 12 junior hospital doctors who are in disagreement—I shall not say in dispute—with the consultants managing the team because they are allowed only 30 days' study leave a year between the 12 doctors. The normal allowance should be 360 days. Therefore the team should be 13 and not 12. That is a reflection of budgets and efforts to control costs. I think that it needs to be written into the status of the national hospital trusts that they must allow effective time for study as well as training. After all, some of those junior doctors will be consultants, others will be GPs. They all need the right sort of experience.

While on the subject of GPs, I should like to say that I am surprised that the working paper on the larger GP practices makes no mention of trainees in those practices. Such practices are the obvious ones to have one or two trainees. I believe that that is an important point which may need consideration.

Research is currently a requirement for promotion to the consultant grade. Again, and probably for perfectly good reasons because the White Paper mentions the reply to other reports, I do not believe that that question has been sufficiently considered. In the old days registrars often had time to carry out research in conjunction with their clinical work. Now the pressure resulting from the number of patients, the turnover of patients and the size of clinics restricts their time for research. They need to have time off for research. I believe that that point needs to be considered within the hospital budgetary plan. One needs to see how that can be fitted into the whole concept of the training of doctors.

Consultants need to supervise research. Consultants need to supervise training. They need to attend conferences themselves. Very often consultants' contracts make no allowance for such absences and consultants are then criticised for not doing their full whack or contracted sessions. There may be a need to appoint more consultants. Management by consultants will require their training in some management techniques and an understanding of the budgetary controls and management information that they are to receive. Will that be allowed for? Will they be allowed time off? Will appropriate courses be given?

Again on the subject of consultants, it must be realised that in the old days clinics and ward rounds provided a significant element of teaching. Nowadays the lists for clinics are scheduled on such a tight basis that they overrun grossly if a consultant spends more than the absolute minimum of time showing his junior doctor a critical point and asking that doctor to carry out examinations on patients and find the information out for himself. I do not think that enough time is allowed in that respect. That point does not appear to receive a mention in the reference to the need for more consultants in the White Paper and it is a point that certainly needs to be reviewed.

I welcome the idea that consultants' contracts will be clarified. I think that there are frightful problems at the moment. One talks broadly about appointing 100 new consultants. Does that refer to effective consultant weeks; that is, involving the appropriate number of 10 sessions? Will there be 1,000 or 100,000 new consultant sessions or will there be 100 bodies who may not work more than eight sessions? That point needs clarifying.

Consultants are not just senior doctors; they are trainers. They will now be managers. They need to keep themselves up to date. They need encouragement as well as criticism and they will become an important part of the final matter that is crucial to this White Paper—medical audit. In many cases, consultants will have to chair those medical audits. They will have to be good man managers to ensure that criticism which will inevitably arise is not hurtful but constructive. In some cases they will probably need training themselves in how to carry out those medical audits. Medical audits can be thought of very much as cost-saving exercises. They will show where some treatments have cost more than others, but they will also point up where better training, which may mean more costs, could have produced more effective treatment.

I believe that the White Paper is a good basis for the future discussions. I am sure that they will prove fruitful and I hope that the results will mean that we have a better service after the consideration has taken place.

6.57 p.m.

Lord Nugent of Guildford

My Lords, I should like to start by thanking the noble Lord, Lord Hunter, for giving us the opportunity to debate the White Paper today and for such an interesting opening speech. I sympathise a little with his regrets about the research situation and particularly with the burden of his report from the Select Committee in which he took part that my noble friend says he is now considering. It is a fact that our research capacity has shrunk in recent years.

I thought that the article in The Times last week which gave an analytical comparison between health services in our country, the United States and Canada threw some light on this matter of our diminishing research resources. Our health service came out about half way between the United States and Canada. Canada was the most satisfactory and America the least satisfactory. As we spend a good deal less than either of them, we might take some consolation from that.

However, an important point not shown in that survey—this is the point that I want to draw to your Lordships' attention—is the increased annual rate of spending on the health service in the past 10 years. The survey covered a period of 26 years and was obviously an authoritative survey done by Americans. It showed that the annual rate of expenditure had been increasing here over the last 26 years at a rate of only 2 per cent. compared with Canada and America where the rate was about 3 per cent. That was a rather depressing observation indicating that we were falling further behind and that we would be less able still to keep up with our research work.

In addition, the survey did not show that over the past 10 years, expenditure on the health service has gone up from £8 billion in 1979 to £26 billion, as my noble friend Lord Belstead told us this afternoon; that is a 40 per cent. increase in real terms, so the average increase in the rate is now up to 4 per cent. per annum and therefore the figure exceeds that of both the United States and Canada. We therefore have some prospect of catching up. This is an encouraging perspective and, if I may say so to my noble friend the Leader of the House, it is a credit to the Government that it has been achieved by the stronger economy of the country.

I should like to turn now to the White Paper and join with other noble Lords who have welcomed its exposition of the Government's plans for decentralising control of this huge national service employing about 1 million people. My noble friend Lord Trafford made a good point: it is rare that the centre decentralises control to the periphery and it is to be welcomed. As I see it, the general theme is to relate the provision of cash more nearly to the patient's needs, both at GP and hospital level, and at the same time to make the service more sensitively responsive to the needs of each individual patient so that each will receive as good treatment as the best.

The White Paper sets out a number of good new ideas and many noble Lords have welcomed them. They are worthy of consideration by all who are interested in the development of the health service. It is therefore regrettable that the noble Lord, Lord Ennals, leading for the Opposition, Members of another place and the noble Lord, Lord Bruce of Donington, have chosen to rubbish the White Paper and discredit it nationally by the charge of preparation for privatisation which it quite obviously is not. I am sorry that neither of the noble Lords are here, but I hope that other noble Lords will pass on to them the message that I have for them. I commend to their attention the March number of Marxism Today, the journal of the Communist Party. I see a smile on the face of my noble friend. The article states: To those on the Left, a discriminating response is appropriate. Outright rejection of the White Paper would be both wrong and a missed opportunity". I emphasise the last point—"a missed opportunity". This is a great opportunity. We might not agree with all of the White Paper, but it is a missed opportunity if we simply rubbish it. I hope that this good advice will be accepted so that everyone can contribute constructively to the discussion.

Lord Prys-Davies

My Lords, as I followed the reasoning of my noble friend Lord Ennals, his concluding advice to the House was that presented by the noble Lord, Lord Hunter, that one should proceed to test the hypothesis before we apply the plan nationally.

Lord Nugent of Guildford

My Lords, it will need a great deal of effort to explain that the intention of the noble Lord, Lord Ennals, was to proceed in that manner. I hope that the discussions on the eight consultation papers will be proceeded with constructively.

I should like to comment on the self-governing hospitals. Incidentally, I observe from the consultation papers that each hospital will contract with its respective district health authority for the core services, including the whole range of local services that may be required, settling the fees on a three-year rolling basis. I welcome the confirmation of my noble friend Lord Belstead that there is no intention of opting out. That is a complete invention to discredit the scheme. I think that any danger of neglect of local needs is covered by the contract for core services that I have just mentioned.

As everybody knows, the quality of the hospital service and efficiency of management vary widely throughout the NHS. There are many different reasons. One of the principal causes has been referred to; namely, the inevitable financial anomalies that arise from the system of allocation of finance from the centre which does not always fit. What happens is that the most progressive and active hospitals which are increasing their activity and the number of cases which they handle tend to run out of their budgetary money by the end of 12 months and may close down beds in order to keep within their budget, whereas other hospitals which have not been so enterprising have surpluses that they find hard to use up. Nothing could be more inefficient than that. I do not doubt that when we turn to the new system the direct responsibility that will come to the independent self-governing hospital will give a real prospect of full use of resources and good value for money.

The noble Lord, Lord Brain, who spoke before me referred in particular to the importance of the Medical Audit Commission. This is absolutely vital in the management of these hospitals and the quality of service that they produce.

To my noble friend Lord Belstead I say that the preparation for the development of a self-governing hospital will be a major task for each hospital. At present few hospitals have the information technology that is essential for efficient self-government, nor do they possess the co-ordinated computer systems that are necessary for full physical and financial control. All that can and should be made available in order to give those hospitals sound prospects of successful self-government. But it will take time, and the two years suggested by my right honourable friend the Secretary of State seem to me to be a very optimistic estimate. I suggest that a way forward might be for my right honourable friend to choose a small number of major hospitals which are known to welcome self-government and help them as quickly as possible to develop the necessary administrative structure so that they can act as prototypes to guide the generality of large hospitals which are contemplating self-government.

In passing, I should like to commend the constitution which is set out in the consultation paper; namely, the appointment of local people for their qualities of public service and their interest and knowledge of the health service and hospitals generally. I hope that local government will not feel offended; when their members have those qualities of course they will be considered for appointment.

I also welcome the plan to bring into this picture part-time consultants through the hospital. They might be able to serve on the boards of hospitals or indeed, I suppose, on district health authorities. I entirely agree with the noble Lord, Lord Brain, that such men and women are the leaders of the industry. They are high powered, talented people. When they apply their minds to administrative and financial problems they have a great contribution to make.

I conclude with a brief reference to the proposals for the GP service and GP practice budgets. The BMA has sent me a copy of its "broadside" attacking practice budgets, and I thank them for it. My feeling is somewhat to sympathise with them, because from what I have heard this proposal is not all that popular. The fact is that GPs have no experience of living in this kind of financial discipline. What is more, the incentive of a practice budget to efficiency and profit for the practice is not of much interest to them. They have to set that against the financial responsibilities that they will have to undertake. To my mind the BMA's criticism is at least partially justified.

However, the point I want to make is that everybody knows that there is a problem. In many practices there is extravagance, especially in the use of drugs, and there are variations in quality of the service to patients between the best and the least good practices. Therefore there is a problem that needs to be addressed. To my mind it is simply not enough for the BMA to say that the existing monitoring procedure will do. It will not do. It has to be made better. It is in the interests of both patients and taxpayers that the Secretary of State clearly has an obligation to tackle this problem. This White Paper is his suggestion. If it is not found to fit, I hope that the BMA and the profession as a whole will bring their great knowledge and strength to the consultation process to try to find a better way of getting practices generally to operate as well as the best of them.

I give my good wishes to the White Paper and hope that the Secretary of State will make a great success of it.

7.6 p.m.

The Earl of Halsbury

My Lords, like other noble Lords before me I should like to thank the noble Lord, Lord Hunter of Newington, for giving us an opportunity to debate this very important subject. There is nothing like the preparatory work for a debate to force one to get down to the nitty-gritty of reading one's papers, a task which otherwise one might shirk.

During the past 55 years I have committed myself to some eight voluntary tasks, all of them lying in the grey area between the application of science to medicine on the one hand and the administration of public bodies on the other. I am still in play with the last of the series at the moment. During the course of those tasks, I have made many friends with members of the medical profession; some of them are former colleagues, and sometimes I am an ex-patient. What follows is, as it were, a little investigative parliamentarianism. I like talking to the man on the shop floor and though, in the course of my contacts, some of the jargon may have rubbed off on me, nevertheless I must not allow your Lordships to think that I have any medical qualifications whatsoever.

Nothing can run on unattended for 40 years without a major overhaul from time to time. The enemies are always the same: complacency and indifference—complacency with respect to one's own performance and indifference in respect to that of others. That is why a major overhaul is necessary. A radical reform always leaves rough edges, and to leave rough edges in health and safety care implies that we are in a sensitive area where we should tread delicately. In this respect perhaps I may draw the attention of the Government to the fact that whenever one re-organises anything at all there is a temporary sag in morale. It is up to the Government to anticipate that situation by producing such morale boosters as they can to coincide with their radical reform.

I welcome unequivocally three aspects of the White Paper. I welcome the delegation of authority down to the level of contact between doctor and patient, cutting out as much of the bureaucracy as we are encumbered with at present. Secondly, I welcome the increased authority of consultants to specify how hospitals should be run with the managers as their servants rather than their masters and in the interests of their patients and the exercise of doctors' professional skills. Thirdly, I welcome the stick and carrot application of further conditions to the "C" merit awards. I might even accuse the Government of plagiarism since I coined that phrase during the Second Reading debate of the Bill introduced by the noble Lord, Lord Rea. I shall not push the indictment too far. I expect it is just a question of minds thinking alike.

I have been going the rounds of various practices represented by friends. To one I said, "Tell me, what is the single biggest headache in your practice and to what will the White Paper contribute?" His answer was interesting. He said, "London traffic, and in particular the abolition of my right to park, provided I do not do it dangerously, outside a house on a domiciliary visit, and then move on to the next one". He said, "I have actually been towed away while displaying a BMA sticker on my car; so there I was, bereft of transport for my next domiciliary visit, together with a easeful of instruments and unable to practise my profession."

Another comment made to me was this: "Time wasted in fruitless 'phone calls to overloaded hospital switchboards." There again, my Lords, we need authority at working level to enlarge those switchboards so as not to waste the time of GPs in making endless calls. A third comment was that GPs could do quite a lot of minor surgery in their own consulting rooms if they got paid for it. As it is, it is time consuming and it prevents them taking on other paid work. As it is perfectly in order to refer the patient to a hospital, they do so. There again more attention needs to be given to the working conditions of single general practitioners.

Let us go to group practice. The fact that it is a group practice does not, of itself, tell you whether it is a good or a bad practice. Of course one only hears of the bad ones from patients. This is one complaint that has been made to me: it is that emergency and accidents apart, you could only see the partners by appointment, which may be anything up to three or four days ahead; there is no constancy in the GP who is going to look after you; and there is a poor reference system to medical records, so that you may be attended by somebody who really does not know anything about you whatsoever. That is a badly-run group practice.

Let me come to a well-run group practice of four. Here there are four doctors with 7,300 patients registered, operating within a ten-mile radius in a rural area. In their view, 11,000 registrations would require about six doctors, and the difficulty of getting six compatible temperaments working together in stressful conditions goes up very much with the number. In fact, if N is the number of persons engaged in a practice, the number of personal relationships between them is one-half of N-times (N-minus-one)—which in the case of four doctors means six and in the case of six doctors means 15. Therefore the number of personal relationships you have to manage between the partners goes up by a factor of two and a half. That is just a little bit of elementary arithmetic.

However, they always seem to manage to see all their patients the same day as they are called, by appointment. Each partner is on call round the clock one week in four. Their facilities consist of an electrocardiograph, a steriliser, computerised records worked by the secretary and a dispensary. For this they employ a staff of a secretary, a receptionist, a state registered nurse and a pharmacist.

What are their complaints? First, that their contract is poorly defined and they are continually being asked to do more and more for less and less. They are dismayed at the growth of the nonprofessional administrators in the National Health Service, as a proportion of the whole, and they thoroughly agree with the White Paper that much more discipline is required in the dispensation of drugs, because they themselves dispense their own.

I come next to the idea of purchase of facilities by GPs. In the London region a very liberal attitude is taken and general practitioners requisition what they want from the most convenient general hospital: X-rays, haemotology, bacteriology and so on. The GP takes a sample, the sample goes by post to the path lab and the report comes back. In other regions there is a less liberal attitude, and the GP can only get what he wants by going through, and referral to, a consultant. What is the point of making GPs pay over the entire National Health Service for services many of them can get by requisition as of today? What we need is a more liberal attitude all round to GPs requisitioning services such as X-rays—I will not go through the list again—without having to go via a consultant.

I come now to my last two points. The first concerns the White Paper as a piece of literary composition. I am sorry to say that I regard it as managerially illiterate, semantically undisciplined and lacking an organisational chart which would give one a synoptic view of the organisation as it now is and as it is proposed to be. There is no glossary of acronyms and no index; so one searches blindly through nine volumes to try to locate the original reference to some acronym that is puzzling one in volume 9.

Chapter 2 is a shambles of misuse of the words "authority" and "responsibility" in the context of delegation. You can delegate authority; you cannot delegate responsibility. I cannot make another man answer for what I am answerable for: I can only do it myself. If you write the words "delegated responsibility" into an Act, the courts interpret it as meaning delegated power, because there can be no answerability for something you have no authority to do, and the moment you acquire that authority you must be responsible to the source from which you received it. Therefore wherever the word "responsibility" occurs, it should be made quite clear regarding responsibility for what and responsibility to whom. I have given the noble Lord who is going to reply on behalf of the Government a note of these points. I hope I shall have an assurance from him that when the Bill eventually appears before us these semantic indisciplines will be put right.

Lastly, what is to become of the review bodies? We are told that the hospital authorities can appoint people with their own ideas of salaries. What happens to the review bodies? They are vaguely referred to from time to time in the White Paper, but there is no idea given of how they are going to work in the future.

7.17 p.m.

Lord Gisborough

My Lords, the White Paper, which must be welcomed in principle, is more conceptual than detailed. I think there is much anxiety among many GPs as to what it means. Inevitably they do not like change, as is the case with most people. The discussion papers do not appear to have allayed that concern to any great extent yet.

I should like to tell your Lordships of some of the representations made to me. For 30 years GPs have been persuaded to undertake much testing and investigatory work for which they have been paid. It is now perceived that they will only be paid on the basis of bodies on the register. There will be little incentive to carry out investigatory work if they are not to receive any more fees for doing so. Therefore it will discourage GPs spending time on their patients.

As to drugs, obviously cost-consciousness is essential. In some areas already, because of the pressure of that consciousness, there are many low prescribers: in other areas a general practitioners list can contain many elderly people or people with a great incidence of problems. It is very difficult to compare the costs of one GP against another taking into account these sorts of factors. Even if one could compare one practice with another, no two years are alike. In one year there may be a great incidence of a particular problem which necessitates much higher cost of prescriptions.

Too much cost-consciousness may also cause stress. I have been given the example of a case of a skin problem where two drugs may be prescribed. One of them is very messy and comparatively cheap; the other is clean and rather dear. Which one will the general practitioner prescribe in future? Will this not lead to cutting corners and giving patients something which, for the sake of cost, will do the job but is not nearly so attractive?

General practitioners are to be weighted according to the types of patient on their lists; for example, whether there are many people who are old, who need drugs and so on. How is this to be administered? With several thousand patients on their lists, are general practitioners to make a note of every man's age, what his problems are and what he may be expected to have? Even to think of it is a nightmare. General practitioners cannot understand how this will be operated in order to work out the potential of their lists.

There is concern about the implication that general practitioners who send most patients to consultants are less good doctors. I shall give an example of how that may be wrong. One general practitioner at home is a part-time clinical assistant in dermatology. Since she started that job, she has sent more referrals, having recognised the complexity of the problems that she has come across. High or low referrals do not necessarily mean that the doctor is good or bad.

Then there is the question of patients' choice. This sounds very good at face value and probably is in the big cities. There are many doctors to choose from. But there is concern that the patient's perception of a doctor who is good may not be right. For example, a patient may be influenced by a very flash entrance or by a doctor who prescribes a lot of pills. There may be less choice for the patient in practice although more choice for the general practitioner with referrals. However, even that may be doubtful because it is stated that the health authority may advise one hospital or another. That means that the important link between general practitioner and consultant whereby the general practitioner knows each consultant and can send patients to the consultant whom he regards as the most suitable will tend to be broken. In any case, general practitioners can already send patients to the hospital of their choice and obtain the surgeon of their choice to suit the patient.

Capitation is also good in the big towns; but in the country areas there is a limited number of patients for doctors to attract. Therefore, the point is rather lost. General practitioners may have to reduce the number of people in their practice. If they cannot find more patients but wish to increase their capitation, all they can do is reduce the number of doctors in the practice.

There will be winners and losers. The White Paper seems slanted towards the acute problems. It is expected that the losers may be the chronic patients in the spheres of rheumatology, geriatrics and perhaps community care. A particular worry exists among small practices in country towns and areas.

In the drive for efficiency there must not be a devolving to the cheapest hospital. The White Paper states that the hospital must be charged out not only on its costs but also on its capital assets. It therefore seems possible that an efficient hospital in a high capital area will have to charge far more than an inefficient hospital in a cheap area. Thus the efficiency of the hospital will be hidden by the capital asset of the hospital.

If hospitals are competing on price—this, again, in principle is right, but it produces problems—for a particular operation, they will inevitably be under pressure to release all their patients as early as possible in order to carry out the operations within quoted prices. If there is a relapse because the patient goes out too early as a result of cost cutting, general practitioners want to know who picks up the tab: does it go against the hospital or does it come back against the general practitioner?

There is no prediction of the increase in administrative costs. With cross-boundary charges there will be considerable extra accounting for relatively small charges. It is estimated that the administration on accounting will double. If the administration charge goes up, there will be less money to spend on the patients. I think that flexible organisation for wages and salaries is an excellent idea. It will help to fill some of the posts where this is difficult by virtue of area and by virtue of discipline and where problems exist in attracting nurses.

While wages may be varied in order to fill different disciplines, it is very important that this should not increase the North-South divide. In the north of England we have very good doctors and good hospitals; and we have nothing to complain about. If the affluent areas were able to offer big sums to attract away all the best doctors, it could lead effectively to a North-South divide, which would be wholly unacceptable.

The concerns of general practitioners need to be pointed out. I hope that they will be taken into account. The White Paper sets a new style for the National Health Service. The fears must be allayed and the details spelt out. Even those who have these fears appear to believe that the White Paper is fundamentally on the right lines and that something needs to be done. It deserves a good welcome and will help to bring the health service into the 1990s.

7.28 p.m.

Lord Rea

My Lords, I thank the noble Earl, Lord Halsbury, and the noble Lord, Lord Gisborough, for voicing the doubts and difficulties of a number of general practitioners at the sharp end. I have heard many of these worries myself, and can echo them from my own experience.

Like many noble Lords, I frequently receive promotional material through the letterbox—probably more than most because I am also a general practitioner. I usually find that the glossier the cover and the more persuasive the language the more expensive and less relevant to my real needs is the product on offer. I rather feel that the White Paper can be described in those terms, but in fact it is not all bad. Some useful and important parts of the policy described in Working for Patients are as follows:

Some doctors—the noble Lord, Lord Winstanley, is one of them—and all health economists, have been pressing for years for more accountability so that those who make clinical decisions can be made aware of the costs that they incur. The White Paper certainly does that, with a vengeance—to such an extent that the costs of treatment are given such emphasis that the benefits to patients seem almost to have been forgotten, despite the title of the White Paper.

Many responsible doctors will also welcome the emphasis on medical audit. I very much welcome the remarks of the noble Lord, Lord Brain, on the way in which this should be administered. Working Paper 6 seems on the whole to be a useful document. The noble Lord, Lord Hunter, mentioned that it should be adequately financed and the noble Lord, Lord Belstead, reassured him on that, and I was glad to hear it.

I like the proposal to ask the Standing Medical Advisory Committee, otherwise known as SMAC, to consider medical audit and indicators of clinical outcome. However, at this stage I should like to ask why no mention is made of last year's report by your Lordships' Select Committee on Science and Technology on medical research and its part in helping the health service. The noble Lord, Lord Flowers, has already commented on that in some detail. I very much support his remarks.

The problems involved in introducing the changes proposed in the White Paper will be enormous. In fact a major criticism, as many other noble Lords have pointed out, is that the steps and solutions which it proposes are far too simple; perhaps they could be described as simplistic. They cannot be introduced in the timescale proposed. I believe that the noble Lord, Lord Winstanley, expressed that very strongly.

Surely there must first be careful evaluation of some pilot projects. This must be the way to go before laying down a timetable for sweeping nationwide changes, many of which I suspect will be found to be unworkable.

A national health research authority, such as was proposed by the Select Committee, would be the ideal body to commission research into the feasibility and economic desirability of the measures proposed with enormous enthusiasm in this document but I feel that without adequate studies some of the proposals will fall flat on their face.

I should like to say a little about how the proposals appear to a GP in practice, because I am working in one of those practices which will become entitled to a budget. However, before doing so, I should like to mention some worries I have about the major administrative proposals in the White Paper. If hospitals are to compete or to opt out I want to know what will happen to the less efficient hospitals. Are they to close; even if they are the traditional, convenient neighbourhood hospitals for sizeable populations? The Royal College of Nursing is worried about that. I should like to quote from its comments on the White Paper: These proposals have the potential to create a split health service resembling the pre 1948 elite voluntary hospitals and the local authority infirmaries". I should have thought that the need was more to upgrade hospitals which are not doing well rather than to stimulate those which are attracting patients from outside their own health authorities.

If there is a net flow of patients from one health authority to facilities in another, that can be recognised under existing arrangements and the transfer of funds could be speeded up to make it possible for one health authority to pay another. There is no real difficulty in that except that administrative arrangements are rather clumsy at present. There is no need for the vast changes which are proposed in the White Paper. It might perhaps be economic to let a hospital die, but in that case it would be working against patients instead of for patients if services become less available conveniently in their own districts.

Secondly, I echo several noble Lords and the noble Baroness, Lady Cox, and the noble Lord, Lord Seebohm, in asking where community care is mentioned in the White Paper? It seems quite extraordinary that a major reform of the health service has been proposed without looking at community care as part of the whole picture.

Thirdly, as regards membership of family practitioner committees and membership of the health authorities, to remove local authority members from such bodies is surely going against the spirit of the White Paper which is to delegate the responsibility for managing hospitals to those who are nearest to where the services are provided. Surely the people who are to receive those services deserve to be consulted through their elected representatives.

Turning to general practice, I am worried about the bureaucracy involved in holding a budget. At present I can freely ask for almost any investigation I wish; refer my patients to a number of different consultants, hospitals and clinics; arrange for district nurses to visit my patients at home; and obtain (admittedly not enough) considerable help from social services departments and other agencies. All this occurs without any money changing hands, no billing documents and no bureaucracy. It is a free service and that is what we have been used to. Compared with almost any other country this allows doctors greater clinical freedom and a considerable degree of choice also for patients. I accept that this freedom needs to be tempered with accountability. There has been too little so far.

Despite that our costs have been very low using any international comparative yardstick. But a series of measures to increase accountability are already in operation. For example, since last year a scheme called PACT—prescribing analysis and costs—has been sending reports to all general practitioners in the country giving details of their prescribing patterns and costs. It is a major innovation which has only recently started and has not yet begun to bear fruit. I think that it will do so quite soon and it should put a downward pressure—using the words of the White Paper—on costs. This effect has been demonstrated by Dr. Conrad Harris and his colleagues of the Department of General Practice at St. Mary's Hospital, who looked at the prescribing habits of a group of doctors and later discussed with them their exact prescribing details.

The General Medical Services Council of the BMA is at present negotiating with the Department of Health the implementation of the White Paper on primary care, which itself will increase accountability. It does not seem to me that the profession has been dragging its feet in these negotiations, as has been suggested by the Minister. I have seen the GMSC's statement describing the negotiations. Of 33 items under discussion, agreement has been reached on nearly all of them. There are only one or two sticking points.

It seems that now the department has moved the goal posts with the introduction of the White Paper. The most retrograde move relevant to the negotiations that the GMSC is having is to decrease the basic practice allowance and increase the capitation element of general practitioners' remuneration. The argument is that this will encourage practices to take on more patients. The better the practice the more patients will be attracted. But that flies in the face of the trends of the past two decades, in which the number of patients per doctor has gradually decreased thereby allowing a little more time for consultations, for listening to patients' problems; and for making fuller and more accurate diagnoses. In other words, a higher standard of medicine leading to a wiser use of hospitals. The profession would be right to stick to its opposition and I shall support it in every way. It would be the beginning of the return of general practice to its impoverished and second rate status as existed before 1966 when the general practitioners' charter was introduced.

I should like to raise many more points but I have already spoken for 12 minutes. However, I should like to refer to a paragraph in the White Paper dealing with the employment of new consultants. It is proposed to create 100 additional consultants over three years; that is 33 per annum. It is claimed that that will help reduce the working hours of junior doctors. In fact, the number of consultants is increasing by approximately 300 per annum; that is, by about 2 per cent. In order to have a significant impact on the working hours of junior doctors it has been calculated that there must be an increase of approximately 600 consultants per annum; that is 4 per cent. Therefore, an increase of 33 per annum over three years is only a small contribution to the problem.

I thank the noble Lord, Lord Brain, for raising the difficulties which may be introduced for junior doctors because the hospital trusts may have different working contracts for their junior doctors.

In conclusion, I suggest that the policies contained in the document will not be "Working for Patients". They will not even be working for health. Preventive medicine and the care of chronic illness are scarcely mentioned. I suspect that the document will not even he working for the Treasury because the necessary additional accounting and billing will more than offset any savings. As my noble friend Lord Ennals said, it will be working for accountants and will provide a boost for the computer industry. I fear that many square miles of forest will be consumed in generating rolls and rolls of computer print-out.

7.42 p.m.

Baroness Masham of Ilton

My Lords, I should like to add my thanks to my noble friend Lord Hunter of Newington for initiating this debate on the White Paper. As these are very early days, with the working papers just having come out, I am sure that this debate on the National Health Service reorganisation is one of many which your Lordships will undertake in the period of consultation.

With the great interest and experience in health matters which exists in your Lordships' House, it is a great pity that there is no Minister from the Health Department to answer our many questions and queries. We are of course honoured to have taking part in the debate the hard-working Leader of your Lordships' House.

I have been in your Lordships' House since 1970 and never has communication with the Health Department been as poor as it is at the present time. For several weeks I have been waiting for an answer to a very important letter. The amusing aspect is that today I received an acknowledgement stating that inquiries are taking longer than expected.

Tomorrow is the by-election in the constituency of Richmond, North Yorkshire, near my home. Last weekend I met three keen young men who had travelled from London to help with the canvassing. I asked them what were the main issues of concern expressed by the people they visited. One might think that it would be farming, water or even eggs. No, my Lords, it was health care. The young men were amazed by the number of elderly people living alone in isolated houses, some of them about 40 miles from the nearest hospital.

The White Paper and the working papers are well laid out and attractively presented. The country must evaluate whether the radical changes will really work in the interests of patients. Will the new structure for regional and district health authorities make an improvement? Will the chairman's job become almost impossible? It is proposed to reduce the membership from 17 to five non-executive members. Who will chair the various committees such as the ethical committees, the hospital chaplains' committees and the regional health authorities' drug advisory committees? Are those committees to be disbanded? Are they not a means of bringing people together and of monitoring performance across the regions? Districts which perform well can stimulate others to do better. Will the knowledge which crosses districts be lost?

The National Health Service has many complex areas. There are many good general managers and paid officers but some are better than others. Where there is too much power self interest can creep in and an autocratic attitude can prevail. That is not good for working relationships within units and authorities. The non-executive members are not paid. Their interest and time is given for the benefit of the National Health Service.

When discussing the reduction in membership the chairman of a district authority said to me, "I just could not ask my members to do more than they do now". Both the regional health authority lay members and district members help to make health authorities closer to the people. They support the chairmen. They help to smooth difficult situations which may arise with the press and the public. They undertake numerous duties such as chairing appointments committees and hearing appeals.

For example, in the Yorkshire Regional Health Authority there are 17 health districts spread from the rural areas of the North Yorkshire dales to the deep industrial areas of Bradford and Huddersfield with a high ethnic population. Will only five lay members be able to do justice for a region so diverse in its composition? I hope that somehow the Government will realise that it is not only money which raises morale in the health service; it is an interest in what people are doing and achieving. It is also a commitment and service which many people throughout the country give freely and willingly.

I should like to ask the Government a few questions and I implore the Leader of the House to try his hardest to arrange for our questions to be answered. First, how will regions and districts be able to cover all the needs of patients if hospitals which now cater for specialised needs become independent and decide that specialised services are not in their interests? On the other hand, what will happen if they increase special services and cannot cover the needs of the general population? What will happen if a large hospital goes bankrupt?

For example, there is in Leeds the biggest hospital in Europe, the St. James' University Hospital, which specialises in renal and liver conditions and has one of the country's leading children's leukaemia wards. When I was there a short time ago the hospital was full. The doctor in charge was trying hard to find 10 beds needed for the night's emergency admissions. Some hospitals are already bursting at the seams. They are already working at 100 per cent. If more services are bought in from the private sector there will be a problem: many private hospitals are inadequate and often cannot cope with the seriously ill patients. They often lack junior medical cover, especially at night. Will the Government safeguard supra-regional specialties? There are some very worried patients. If the Government have any kindness in their heart, they will make a statement that these specialised services will be safeguarded. For example, the Phipps Ward, which is part of St. Thomas' Hospital, is the only unit in the country serving high respiratory patients. It is their lifeline. Will the spinal injury units which look after patients who are paralysed from breaking their back and neck still be funded by central government? What happens at a busy general hospital like Stoke Mandeville if it chooses to go independent and does not want to administer the spinal unit? Will the regional renal units be safeguarded?

The big vacuum in the White Paper is the lack, already mentioned, of community care. At the bottom of page 15 of the White Paper, when it mentions therapists, there is no mention of occupational therapists. Those therapists are a very important link with the community when patients are to be discharged. There is a shortage of occupational therapists and the absence of mention about training of therapists is causing concern.

There is also concern that no mention has been made of the wheelchair service which will start incorporation into the health authorities in 1991. It is important that that transfer is thoroughly thought through and implemented smoothly and effectively with no loss of continuity of service.

Many people will welcome the statement in the White Paper which makes the health service more responsible to the needs of patients. As much power and responsibility as possible will be delegated to local level.

The proposal to give people individual appointment times for outpatient attendance is also welcomed. In particular, many disabled people find long waiting periods distressing. However, in order to make this proposal a reality the problem of transport to and from clinics needs to be addressed. It is important that all the needs of disabled people are incorporated in the restructuring of the health service.

Disabled people need reassurance that they will be accepted onto the general practitioners' lists. With so much emphasis on the budget of GPs, some disabled people already feel insecure. Such disabilities as head injuries, epilepsy, kidney disease, diabetes, spinal injuries, sickle cell anaemia, rheumatoid arthritis and many other chronic conditions will never be cost effective to the general practitioners. One GP said to me once, "The good patients are the ones we do not see". The good GPs will always want to do their best in the patient's interest. There should be good trust between the GP and the patient. The encouragement in the White Paper to increase the lists of patients cannot mean a better service for patients. Many GPs already do not seem to have much time for patients. Illness is a complex procedure. The Government will have to do something about protecting high cost patients.

It is impossible always to be correct in the time that a patient will stay in hospital. Each patient responds differently. They are not like tins of peas passing along a conveyor belt. They respond differently to stress and their immune systems work in different ways. They are human beings with feelings.

Doctors become doctors to treat patients. Many of them do not have the skills of an accountant. Everyone should try their best to be cost effective—there is no doubt about that. However, the question we should ask is: will budgeting become a burden to the general practitioner and take his mind away from his patients? The patient needs a quality approach. Will the businessman's approach give that? If the patient is to have a good relationship with his GP, he should be able to help make the choice when he goes to hospital. If he feels that he has been sent to the cheapest option and problems arise such as an operation going wrong, what will happen? Who will he sue?

One of the vital links in a complicated network is for the Government to find ways of unblocking the acute orthopaedic and general beds where elderly patients are residing because they have no suitable place to go in the community. The missing link is the lack of community support. Should not some pilot schemes be tried out before too much is changed too quickly, before safeguards are drawn up?

7.55 p.m.

Lord Mottistone

My Lords, it is always a privilege to follow the noble Baroness, Lady Masham. I hope that she will forgive me if I touch only once or twice on what she said.

I should like to start by congratulating not only the noble Lord, Lord Hunter, but also the Cross-Benchers for allowing this day to be devoted to the present debate so early in the life of the White Paper. I should also like to congratulate the Government on making proposals which, in general, are sensible and stand a good chance of providing improved health care for patients.

As a one-time quango manager, I welcome the improvement in management methods; for example, the increased delegation towards the working level, the smaller health authorities, the self-government for hospitals, the reduction of red tape governing the financial interchange within the NHS and the family practitioner committees becoming accountable to RHAs alongside DHAs. That should all lead to improved service to the customer as well as better value for money.

One hopes that in time there will be greater decentralisation for pay and conditions in the service. In a labour intensive activity like the NHS, truly effective decentralisation of management can only be achieved by similar decentralisation of control over pay and conditions. The proposed arrangements for hospital self-government are a splendid move in that direction and one from which in due course the customer will surely benefit.

However, although I greatly welcome the proposals in the White Paper in general—and there are many other examples which could be mentioned with acclaim—there are three areas in which I take a special interest where the implementation of the proposals could have adverse consequences. The noble Earl, Lord Halsbury, encouraged the Government to go delicately in those areas. I too say that they should be treated with care. Those areas are the Isle of Wight, the handling of mentally ill patients and optometry.

In a general paper like the one now under debate, it is natural that a small county like the Isle of Wight should not receive special mention. However, it is of particular note that it houses the only district health authority in the country which is cut off from the mainland by sea. Thus it is of importance that the arrangements for the funding of hospital services described in Chapter 4 are implemented with a clear understanding of the special difficulties there may be for the islanders and their GPs to shop around for hospital services. That is merely one example. There are many other potential difficulties due to the Isle of Wight's unique position and I hope that the Government will give particular care to that point.

On the plus side, the Isle of Wight has the immense benefit of identical geographical boundaries for its DHA and its county council. This makes liaison between the health authority and the social services vastly better than on the mainland. Many noble Lords have commented on the lack of coverage by the White Paper of community care or even social services. Indeed, the noble Baroness, Lady Masham, finished her speech on that point. The noble Lords, Lord Rea and Lord Seebohm, mentioned it. My noble friend Lady Cox spoke about a seamless robe incorporating community care. Whether or not covered by the White Paper, I tentatively venture to say that in regard to those aspects liaison and coverage are better handled in the Isle of Wight than in most other parts of the country.

On more than one occasion I recommended to my noble friend Lord Skelmersdale, when he was responsible for health, that one of the changes that could usefully be included in the White Paper is to rearrange the regional and district boundaries to coincide with those of the counties in order to achieve the very situation I have described. I very much commend to my noble friend who is to reply that he pass on my suggestion to his right honourable friend as it could be carried out even though it is not mentioned in the White Paper. The co-ordination of those activities would be vastly improved if my proposal were to be implemented.

Turning now to the mentally ill, my main concern is that I find very little mention of such patients, or care for them, in the White Paper or in its eight supplements. For example, one in 100 of the population suffer from schizophrenia at some time in their lives which, in a relatively small community like the Isle of Wight, is 1,200 people. Therefore it seems to me that they provide a special problem of great importance which justifies special measures in research, in care within hospitals and in supervision outside hospitals.

I should have liked to see mention of the more common mental illnesses in the annexe to Working Paper No. 3. I suppose those who look at it will not think it entirely appropriate. One can say that, after all, psychiatric services are included in the core services in paragraph 4.15 of the main paper. One would have thought it likely that there might be a waiting list for such services in view of the known demand for them. Perhaps there is not a waiting list for psychiatric patients in hospitals. I suggest that that is not because the cases are not there but because the psychiatrists will not handle them, for one reason or another. We need to make quite certain that in the implementation of this White Paper proper attention is given to the problem of this important illness, which has not received nearly enough interest in the Department of Health, the NHS or in the general world of research, about which others have spoken.

Turning now to optometry, it is clear from the Health and Medicines Act that the value of this most useful supporting service is neither understood nor appreciated by Ministers. While I welcome as good managerial practice the small size of the health authorities and the family practitioner committees, it will in fact be the first time since the formation of the NHS, some 40 years ago, that there has not been an optometrist on each of the family practitioner committees.

Though FPCs are to consult local representative committees, we need to be sure that they pay more than lip service to such consultation. After all, NHS-subsidised eye examinations are still available to 40 per cent. of the population so there will be at least 5 million patient contracts a year under GOS. In addition, presumably FPCs will still be required to enforce terms of reference for optometrists under the NHS and to administer complaints procedures in regard to eye tests. It is difficult to see how they can do that effectively with the optometrists only acting in a consultative role. I hope that my noble friend will take note of that to pass on as an aspect that needs proper address when the White Papr is implemented.

To conclude, there is much that is fundamentally good about this White Paper and its eight supplements, but we need to watch carefully to see that important specific health matters are not overlooked in the implementation of the proposals.

8.5 p.m.

Lord Butterfield

My Lords, I should like to add my thanks to my noble friend Lord Hunter for giving us the opportunity to debate the White Paper so soon after its publication.

I welcome the White Paper not least because for the whole of my career since the health service began I have been trying to make a good case for more funding. I have been told repeatedly by people who know better than I that the service is a bottomless pit. It seems to me that the examination that lies behind this White Paper is a necessary planning feature before there is much prospect of more money finding its way to this important service that I love so much.

I recognise that the central problem—this was mentioned by the noble Lord, Lord Ennals, and my noble friend Lord Seebohm—is that there is an enormous amount of work to do to make sure that the money can follow the patients. One aspect about which we are all concerned is the age of the patients. My elderly mama died not long ago and I was reminded that people over the age of 85 cost the health service about 22 times more than people in middle life. That is a devastating figure.

I also welcome the delegation of responsibility but I am conscious that it will bring together new people. I hope that we are able to ensure that close and happy collaboration can develop between them.

I am very much in favour of audit. For a long time I have been chairman of a committee concerned with merit awards. I hope the fact that people are to be reassessed at three-year intervals does not introduce tensions and resentments between the profession and those concerned with the two procedures. It has been said that they should be kindly procedures and I certainly agree.

Like my noble friend Lord Seebohm, I too greatly regret the absence of more integration in the presentation. It seems to me that medical practice in the hospitals as well as in the community will depend very much on smooth relations between the social services and the health side. I was much involved with that long ago when I was at Guy's Hospital and we were trying to devise an integrated plan for the new town of Thamesmead. Rather as with the White Paper, we had the enormous advantage that Thamesmead had not been built so there were no patients and our plans could be idealistic about how far people would walk to see the doctor in rainy weather, and so on. However, the central purpose of that development was to bring all the people together to work collaboratively. I believe that should be the aim on this occasion.

I should now like to take up three specific points from the White Paper and the working papers. I refer to the start of paragraph 30 in chapter 4 on page 38 of the White Paper. It states: The Government is firmly committed to maintaining the quality of medical education and research". First, perhaps I may make a few remarks about education. I am quite sure that my noble friend Lord Dainton was correct when he indicated how valuable it would be if somebody with a feel for education and research could be found a place on the policy board and on the management executive. It seems that at the end of the day the quality of the service depends on the education of the doctors, the nurses and the professions. Yet repeatedly, as we have been trying to improve the NHS since the 1970s, I have felt that the educational side has received a cold wind. I believe that the time has come for that to change.

I am sure that my noble friend Lord Brain was right about post-graduate training. It will have to be extended to include management skills. That will put a heavy onus on those who are responsible for post graduate training in all our hospitals. I confess that I was disappointed with Working Paper No. 2, paragraph 4.11 at page 20 where it deals with research. It refers to your Lordships' Select Committee on Medical Research for the NHS. I believe that it was a very weak statement because it left out what seems to be a really central theme that the noble Lord, Lord Nelson, and his colleagues had unravelled; namely, the terrible paucity of operational research in this vast 1 million-strong personnel enterprise. I feel very strongly about that because I have no doubt that operational research will be a very important factor in whatever developments emerge from the White Paper.

I also have a personal reason for being concerned about operational research in the NHS. As I get older and greyer I have become more and more concerned with the preservation of health, health education and promotion. I have no doubt that it will require the best techniques of operational research to do the kind of survey work that some of my young colleagues have been undertaking. I hold up this report although I realise it will be visible only to the television cameras. It is a report concerning a study of 9,000 folk taken at random up and down the country. It looks into their health knowledge and behaviour. Some of the results are most distressing. There is undoubtedly an enormous amount of health ignorance abroad in the country.

It is my belief that if that kind of information could fit in with the activities of the districts and regions it would provide a wonderful assessment of the quality of health. Once we have a base line for that in any district we can repeat it after five years and begin to get an idea of where the health service is failing to preserve health. That is something that the patients are very interested in. It links very closely with one of the early points made in the White Paper. It states that one of the matters that district health authorities can start to concentrate on is ensuring that the health needs of the population for which they are responsible are met; also, that there are effective services for prevention and control of diseases and the promotion of health. That is why I regret that the Government have not yet grappled with the question of operational research in the review of the health services.

I am taking a very small book from my pocket because I believe that there should be yet another publication which would be called "Working With Patients Towards Achieving Better Health". I rely on my little book for a quotation from Hippocrates that I frequently use with my students. They all know the great aphorism: Life is short, the art long, opportunity fleeting, experiment treacherous, judgment difficult". That is to be found in almost every medical textbook. But in the same aphorism the great Hippocratic school went on to say: The physician must be ready not only to do his duty to medicine himself but also to secure the co-operation of the patient and his family".

8.15 p.m.

Lord Auckland

My Lords, the noble Lord, Lord Hunter of Newington, has the House very much in his obligation for this very important debate, especially as it has enticed here a number of noble Lords with great experience of all parts of the National Health Service in research and medicine of all kinds. At this time of the evening and being not the llth batsman but the 25th—if one had a cricket team of that size—it is necessary to cut down one's speech.

After 41 years of a National Health Service it is quite clear that some kind of reorganisation will be necessary. There has been no shortage of reorganisations of the National Health Service, sometimes in the form of Royal Commissions chaired by very distinguished persons in the health service and elsewhere. I believe that whatever shortcomings these proposals have they put the National Health Service on a more realistic basis than it is now. Market forces always have shortcomings. I believe that this will be clear as the implications of the White Paper go forth.

On the other hand, it is becoming more and more vital that those experienced in the field of medicine should have more opportunities than those who are in what I call theoretical marketing. I join other noble Lords who are disappointed at the scant amount of discussion on medical research. Last week I was at a diplomatic reception and I met a very distinguished gentleman who was one of the head men in the Imperial Cancer Research organisation. I talked to him about this particular debate and he said, "Please mention one point if you can, that is, the vital importance of medical research and the lack of funding therein".

I accept that medical research, like any other kind of research, can have its fallibilities. It may well be that research into some subjects has been duplicated. It is surely absolutely vital that we combat some of the more menacing diseases, particularly in children, and Alzheimer's disease in elderly people. Those or your Lordships who watched last Monday's "Panorama" programme will have seen the very distressing implications of that particular illness. There are also the childhood leukemias. Medical research has much to its credit for having at least given remission to many of these conditions. Unless we have more financial assistance for medical research we shall never completely cure these conditions. I join with other noble Lords in imploring the Government to look at that matter.

Lord Bruce of Donington

My Lords, I am most grateful to the noble Lord for giving way. In connection with medical research, will he confirm that a graduate microbiologist engaged in research on Alzheimer's disease is paid less than a corporal in the British Army?

Lord Auckland

My Lords, I defer to the noble Lord's greater knowledge. I am not professionally involved in the matter but it is an important point that people working in many aspects of medicine receive rewards which certainly do not compare well with those available in the defence forces and elsewhere. That is one of the quirks of life. It is not a state of affairs peculiar to this country but I hope that the Government will take on board the noble Lord's point.

The setting up of hospital trusts is a good idea but it needs to be explored carefully. Out of the 11 people to be appointed to the boards the White Paper says that only two will represent local people. It is suggested that one will be drawn from the hospital's League of Friends. I declare an interest as the president of the friends of our local district hospital. More local involvement in these trusts is vital. I am a trustee of a school. In order to make the trusts work it is essential that trustees should have local knowledge. Between now and 1991, when all the facets of the White Paper will come into force, I hope that this matter will be looked at. It is a good thing that the requirements of the White Paper are being phased as some aspects need very much closer consideration than even two years can give.

The Royal College of Nursing is rightly concerned about the facilities nurses will have for negotiating pay rates and conditions of service in hospitals that opt out. This is an important point because there may be a suspicion, perhaps unfounded, that hospitals which do not conform to the White Paper will not receive the same favourable consideration, particularly in regard to staffing and negotiating pay rates, as those which do.

Time is moving on. This has been a long debate but I would urge the Government to make haste slowly in these matters. The White Paper has some excellent facets but it also contains a number of matters which need closer consideration than two years can give. Many Members of Your Lordships' House and indeed many members of the medical profession who after all will have to work these proposals think along those lines.

8.24 p.m.

Lord Stallard

My Lords, I should like to thank the noble Lord, Lord Hunter, and his colleagues on the Cross Benches for initiating this debate and for allowing us an opportunity to discuss the Government's proposals for the future of the National Health Service. At this stage in the debate it is difficult to avoid repetition but I shall do my best. I have cut down my remarks to what 1 consider to be two major points which have not been fully dealt with.

I certainly do not have the medical expertise of most noble Lords who have spoken. My background has been mainly in public health and community health. I was chairman of various health committees, a member of the LCC divisional health committee, a chairman of interviewing panels for senior and junior hospital staff, and a member of my own area health authority until it disappeared. I have been closely involved, and still am, with voluntary organisations dealing with community health, the elderly and mental health.

I served on those committees in my capacity as a member of a local authority; first of all, of the old St. Pancras Borough Council and then on the newly formed Camden Council until I left. In addition, I attended umpteen seminars, training courses, conferences and working parties, all organised by hospitals and health authorities, in my capacity as a member of a local authority. I was privileged to be involved in some of the early joint appointments which aimed to bring together hospitals and the local community in the development of services. I was involved in the planning and provision of health centres and health clinics and I took part in encouraging, where possible and practicable, the setting up of group practices.

I do not say this to boast or to make a personal point out of it. I believe that I am representative of thousands of men and women of all political parties and trade unions who served in that way. They gave up leisure time and made personal sacrifices willingly, voluntarily and without being paid because they believed they were providing a necessary ingredient in the task of developing services for the community. They were bringing an important voice into consideration of these services at all levels. Many of those people went on to become Members of another place and even of your Lordships' House. Many of them have made major contributions in ministerial positions.

All that is about to be changed. Paragraph 8.6 on page 65 of the White Paper says: Local authorities will no longer have a right to appoint members to DHAs". In that one sentence the Government destroy what has been built up carefully over many years by thousands of people; and for no apparent good reason. On the contrary, there is every good reason to involve more and more people with local knowledge and local interests. There is no apparent good reason for that destruction. But we are all aware of the new atmosphere of hostility between central and local government these days. While I certainly would not defend all the activities of local government in recent years—indeed, far from it—I would equally not defend the Government's destructive, negative and dangerous response to the current problems. In my view to shut out this whole body of opinion may create a gap which will be filled with something much worse.

The contents of paragraph 8.7 follow on from that. It reads: The interests of the local community will continue to be represented by Community Health Councils, which act as a channel for consumer views to health authorities". I turn now to the community health councils' remit. It seems that they are to take on sole responsibility for representing all the interests which I have briefly outlined—and there are many more. However, to add all that on to their remit is almost unthinkable at present. It does not really make sense. Many practical questions arise the minute one considers whether one should increase the remit.

Will the very small and modest Bill which I had the privilege of steering through the House last year—namely; the Community Health Councils (Access to Information) Act—now be extended, or repealed, or will a new set of proposals be put forward for the new CHCs? Even now those CHCs are understaffed and underfunded. Therefore to take on this new major role of being the sole representative would, of necessity, mean much more realistic staffing, equipping and financing. I do not believe that those resources will be forthcoming; that is not the nature of the Government's proposals.

Therefore I think that the proposals as they stand represent an insult to the thousands of people who I mentioned at the beginning of my remarks and I hope that they will be withdrawn before any legislation is proposed.

My second point is tax relief for retired people on their private medical insurance premiums. That is probably one of the most important proposals and one which will have a much bigger effect on the future of the National Health Service than is generally conceived. Mention of it is contained in paragraph 1.18. It reads: The Government expects to see further increases in the number of people wishing to make private provision for healt1 care"— that is an important passage— but at the moment many people who do so during their working life find the cost of higher premium difficult to meet in retirement. The Government therefore proposes to make it easier for people in retirement by allowing income tax relief on their private medical insurance premiums, whether paid by them or, for example, by their families on their behalf". That proposal is being promoted by the Government as being of benefit to older people. I agree with Age Concern who warn us that, It is important 'not to raise' false expectations…about the extent to which this will benefit elderly people". I think it is worth looking a little closer at the proposal. The truth is that not many individuals pay for their private health care out of their own incomes. Indeed, most payments are made by companies on behalf of their employees through a variety of schemes. Moreover, those payments usually cease when a person leaves work.

While it can be argued that private health insurance offers an entry to acute medical care, insurance does not in general cover certain types of health care to which elderly people have most recourse; for example, long-term chronic conditions such as arthritis, loss of mobility, dementia and many others. In the main the major insurance schemes give a wide range of cover for accommodation and treatment in hospital and for some care outside hospital. However, such schemes almost invariably exclude new subscribers over the age of 64. Longstanding subscribers may be allowed to continue subscribing at the age of 65 but premiums increase sharply at that age, beyond the reach of many pensioners.

The schemes which are open to the over 65s do not provide cover for pre-existing complaints, so the older a new applicant is the more likely he is to have had some previous symptoms or history which would disqualify him from cover. Care in a nursing home or other long-stay settlement; a stay in a convalescent home; or care at home, which is not related to a hospital stay and which has not been recommended by a specialist; care under a GP; regular renal dialysis and dental or optical care would not qualify for cover under most schemes.

Again, I am most grateful to Age Concern for providing me with some figures of the increases so as to illustrate the degree to which premiums for private health insurance increase at age 65. The figures were compiled over 12 months ago and therefore will have quite dramatically increased, along with all other costs, since then. However, they show that for BUPA Care, a single man aged from 60 to 64 in London would by paying £578; at age 65 years and over for a renewal policy only he would have to pay £935. That is a massive increase the minute he reaches the age of over 65. If he is married, and aged between 50 and 64, the premium is £1,068; for 65 years and over, and for renewal only, the premium is £1,869. Similarly, for the PPP Family Health Plan the figures increase from £448 at the lower age to £738 for age of 65 and over; and for a married couple the figures increase from £847 to £1,390.

Therefore we are bound to ask: how many pensioners or old people are likely to have the money to pay such huge premiums? In addition, how many of them will be paying enough income tax to qualify for a reduction on the premium? Those are obvious questions. However, I think we all know the answer. It is, of course, not many. In order to benefit from the proposals you would have to retire both healthy and wealthy.

However, I do not think that the Government are too worried about those numbers. I think that they are more concerned about establishing a principle, because when we read the last sentence again, they say: Whether paid by them or, for example, by their families on their behalf". Then we get a clue. The proposal will be promoted as being "fair". They will say, "It is only fair and just, isn't it?" "Why shouldn't sons and daughters be allowed to pay their parents' health costs and be able to offset such costs against tax?" Indeed, why not? But, what happens then? If it is all right to receive tax relief on your parents' health costs, is it not just as right to receive tax relief on your own health costs? Of course it is. Indeed, that would follow.

Given the Government's enthusiasm for more and more people to go private—they mention that in the same paragraph—I believe that this concession would soon be extended to cover personal premiums as well and so push more and more people, they hope, into the private sector and therefore very soon create the two-tier system on the way to total privatisation. That is not a fantasy; it is a perfectly logical assumption to take from that paragraph and from those proposals, because we know that the Government are almost obsessed with privatisation of everything in sight.

There are many more points which should be raised following the publication of the working party documents. I, for one, have not had a chance to study them yet. Indeed, we really need a separate debate on each paper. For instance, I should have thought that a debate would be most useful on the powers of the new boards, or the boards of directors of self-governing hospitals. I think that we could debate those powers alone in one afternoon.

However, I am convinced that if the Government really listen to the public debate which has started, which will continue and get fiercer as the facts become more available, then they will drop any attempt to force through legislation based on this White Paper and they will restore to the National Health Service the principles upon which it was conceived.

8.40 p.m.

Baroness Robson of Kiddington

My Lords, it is late in the evening and we have finally arrived at the last few speeches. Like other noble Lords, I want to thank the noble Lord, Lord Hunter, for introducing the debate and for starting it with a history of the National Health Service. I also have been involved with the National Health Service for a large part of its history.

It is interesting to contemplate that from 1948 to 1973–74 no changes were introduced into the service; and then, rightly, in 1974 community services and hospital services were brought together. The decision taken at that time with regard to the administrative structure of the health service was wrong and therefore I agreed with the 1982 reorganisation, when we did away with the area health authorities. That meant that within eight years the National Health Service went through two major reconstructions. They caused problems for the staff. It was only shortly after that that the new management structure was introduced which again had a destructive influence on the service.

Here we are in 1989 proposing yet another new system for running the health service. I am pleased that we are debating the White Paper and that the working papers were in our hands shortly before the debate. It is impossible for any speaker in your Lordships' House to absorb all the material in the working papers. I therefore agree that it would be useful to have a debate on specific aspects of the working papers.

Before proceeding with the few points that I wish to make, I should like first to support the request of my noble friend Lady Seear that the community services be considered in conjunction with the White Paper. We hope that the Government's response to the Griffiths Report will soon be available and will be published before decisions are taken on the White Paper. I should also like to endorse the concern expressed as to whether preventive medicine comes into the White Paper.

The noble Lord, Lord Belstead, said that the White Paper's aim was to make the National Health Service more responsive to the needs of patients and to ensure that the money follows the patient. I am sure that we all subscribe to those aims.

There was a great deal of speculation in the press before the White Paper was published. Many people are worried about what will happen to the core services. I was therefore reassured by the statement in the White Paper that they would be protected and that emergency services would be immediately available. That is an assurance that the nation needs when it considers the reorganisation of the service.

I am somewhat disturbed, because I find it difficult to see how that would be achieved under the new financial framework for NHS trust hospitals. A new charging system for capital in the NHS will be introduced. Charges will be made up of two parts—depreciation (calculated on ordinary commercial accounting principles) and interest (calculated on the current value of the capital assets used by authorities). That is new. It is good accounting practice. Perhaps I may have the temerity to suggest that Her Majesty's Treasury produces its accounts in capital and revenue terms.

If that happens—it is bound to happen according to the working papers—those National Health Service hospitals which opt to become trusts will have an enormous amount of freedom to raise capital. They will be able to borrow; and they will be able to build up reserves if their operations are profitable. They will have three types of contract with district health authorities. They can have block contracts; cost and volume contracts (baseline and cost per case) or merely cost per case. In other words, each hospital could have a multiplicity of contracts with various district health authorities.

If the hospital has a block contract with a DHA and a cost-per-case service contract, and can make operating surpluses to build up reserves to improve their services, what guarantee is there, and what are the probabilities, that such reserves will be invested in the core services which, by their very nature, are likely to be less profitable than cost-per-case activities? Is there not a danger that those reserves will be invested in high-tech medicine, where the chances of further income generation are greatest, to the detriment of the core services? Does not that, in a way, make it almost certain that the hospitals which do not elect to become hospital trusts and which are financed directly by the DHAs will be the hospitals that will have to run all the less profitable services? That is not a fair division. It will not make for certainty that the core services will be looked after.

We have battled for years to ensure that the core services are given the right financial support. I should hate to see them once more relegated to the Cinderella position which they once surely occupied. That would be a retrograde step. I also have worries about general practitioners' budgets. Will not running a budget for a group practice of, say, six doctors increase the cost of that group practice? I do not believe that many doctors have the financial know-how to run the finances of their practices. It will inevitably mean that they will have to employ some kind of financial manager. That will add to the cost of the practice.

There will be another change for general practitioners. They will no longer have free tests and diagnoses in the hospitals. They have been used to them. I agree that some general practitioners have not done all that they could for themselves. At the first opportunity they have sent their patients to hospital for tests which may be unnecessary. Is there not now a danger that because it will save some money for their budgets they may not send their patients for tests when it is necessary?

All these are matters which should be discussed deeply. I am very doubtful whether the time allowed for discussion and the time necessary for slowly implementing any changes in adequate. That is not to say that we believe there is nothing good in the proposals. There are many good suggestions in the White Paper but they must be implemented very slowly if we are to make the best use of the opportunity presented to us.

The noble Lord, Lord Richardson, mentioned that hospitals used to be self-governing in the past and that teaching hospitals in particular had their own boards of governors, which worked beautifully. There was wonderful co-operation between the hospital secretary, the head of the medical committee and the matron. It worked marvellously and proved that hospitals can be self-governing. I agree, it does. However, I was a member of a board of governors before 1974 and I wish to remind the noble Lord that in those days the finances available from the Department of Health and Social Security, particularly for teaching hospitals, were such that if we overspent, the budget was automatically topped up by the department. We did not have to suffer the kind of financial control that will be necessary.

I am not saying that it was right that we had no financial control; it was wrong. But I think that a self-governing hospital will have much greater problems than we have ever encountered before. I welcome the opportunity to discuss the subject and I hope that the Government will give adequate time for thought and implementation.

8.52 p.m.

Lord Prys-Davies

My Lords, I join with other noble Lords in expressing my grateful thanks to the noble Lord, Lord Hunter of Newington, for having given us this early opportunity of discussing an extremely important and, in my view, complex White Paper. It is not an easy paper to understand, let alone to see how it will be implemented. Like the noble Baroness, Lady Robson of Kiddington, I am also grateful to the noble Lord, Lord Hunter, for describing the historical setting for the White Paper. One might form the view from reading the paper that the National Health Service started in 1978. The noble Lord, Lord Hunter, drew our attention to the historical background which goes back much earlier. I am also grateful to him for the sound steering which he gave to the debate.

Perhaps I may also express my thanks to my noble friend Lord Bruce of Donington for reminding the House of the philosophical ground upon which the NHS was constructed. I detected in his message the powerful voice of the South Wales valleys. We are grateful to the noble Lord, Lord Bruce, for his contribution.

Of course some of the proposals are sensible. We favour individual appointment times in the hospitals. It is quite outrageous that people should be hanging around for two or three hours in waiting rooms before they are seen by the consultants or the senior registrars. We favour the cutting down of waiting time for an appointment. We favour a more sensitive complaints procedure. We very much welcome the appointment of 100 additional consultant posts and we favour a medical audit. We favour money following the patient if it is in the interests of the patient that he should cross administrative boundaries for treatment which he requires. We are not in favour of putting up boundaries to protect people from the services which they require.

However the debate has mainly concentrated on the controversial proposals contained in the document. In my view it is the most radical White Paper to have been published on the NHS since that bright morning 42 years ago. There is deep unease about the role of the GP under the new regime and the right of the larger hospitals to become self-governing institutions. While it is the Government's case that these changes merely reflect a change of pace, we believe that they herald a change of direction which, unless modified, could undermine the trust which should exist between doctor and patient.

The proposed system will exert very strong pressures on the GP who is a practice budget holder and the NHS manager to ensure that financial considerations come to the forefront in reaching a decision as to the treatment the patient is to receive and where he is to receive it. Let us consider the GP who is a practice budget holder. Here I am pursuing a point made by the noble Baroness, Lady Cox. Having to live within his budget, is there not a risk that the GP will prescribe fewer or cheaper drugs? On the other hand, if he tends to opt for the more expensive drugs to meet the special conditions of his patients, how will they be paid for? What will be the position of the patient who wants to receive his treatment at hospital A if his GP recommends hospital B with which he has negotiated a price? In that situation, if the GP practice budget holder is the sole judge of which hospital the patient is to attend, what does "patient choice" mean? We shall come to that, if it is not so.

If the GP is not a practice budget holder, it will be the health authority manager who will decide where the hospital treatment is to be given. Of course, the manager will be in a position to compare the prices which have been quoted by the various hospitals. But will this manager be in a position to assess the standard of treatment? If the manager has contracted for the treatment to be given at hospital B at X price, must the patient follow the contract or, at the patient's discretion, can the money follow the patient?

I am asking for those answers. I should be grateful if, when he comes to reply, the Minister will confirm specifically that in those two situations which I have just mentioned the patient will go to the hospital of his choice and will not follow the contract. I have done my best to study the White Paper, and the attendant working papers and relative paragraphs. However, like the noble Baroness, Lady Gardner, I have not seen it specifically and unconditionally confirmed that that will be the position. I may have missed the paragraph and I should be grateful if the Minister would refer the House to that paragraph in the White Paper or the attendant working papers which gives an unconditional and specific answer to the question.

Of course the House will be interested in the Minister's reply to the three specific questions raised by my noble friend Lord Carter. We shall be interested in his comments on the thoughtful observations of the noble Baroness, Lady Robson of Kiddington.

It is stated in the working document that the general practitioner and the health authority manager will seek out the hospital best buy in terms of price and standard. But if I may take up a point which was touched upon by the noble Lord, Lord Winstanley, I believe that notwithstanding the Korner information referred to by the noble Lord, Lord Trafford, there are still problems to be overcome by the majority of hospitals in accurately apportioning the total costs of the hospital down to the level of the individual specialty and the individual treatment. My evidence for that is to be found in paragraph 2.16 of Working Paper No. 2.

As financial considerations come to dominate the scene, is there not a danger that some hospitals with an eye on the profit and loss account will cut corners in order to reduce costs? Could that lead to reduced quality? If a hospital decides to concentrate on those treatments which involve a short duration of stay or a high throughput, or on any other treatment which is profitable and which has a glamour appeal, to take up the point so powerfully made by the noble Baroness, Lady Cox, who will plan for and meet the comprehensive needs of a community now served by a district general hospital and the community health services associated with it? Perhaps when the Minister winds up, he will deal with that vital concern. A comprehensive and integrated system has been the objective of the National Health Service for at least 30 years.

I now come to the self-governing hospitals which will provide such core services—that is a new term which has yet to be defined—as are agreed. They will determine staff salaries. If a particular hospital pays top salaries, who will eventually pay the bill? Will it he passed on to the general practitioner and be paid out of his budget? If a particular hospital pays top salaries, is there not a danger that that will affect recruitment for the other hospitals in the neighbourhood? Is that in turn not likely to lead to a two-tier hospital structure in that particular area which could depress morale in the lower tier? If that happens, what then will have been achieved for the patients of that hospital?

It is claimed by the Government that the self-governing hospitals will remain a part of the NHS. That statement has been endorsed by the noble Lord the Leader of the House this afternoon. That may be the position—I put it no higher than that—to some extent at the outset. But we are planning for the future, not just for today. Do the Government not see that, having created self-governing hospitals, they will have created within the system incessant pressures for self-governing hospitals to extend their powers until one day they become totally independent of the NHS?

Does the department not see that it will be driven to concede effective independence to the self-governing hospitals, perhaps in five or 10 years' time? Does it not see that that would endanger the cohesion of the National Health Service? Given their history of independence, I can see why the noble Lord, Lord Richardson, finds the status of a self-governing hospital to be attractive to some teaching hospitals. But I endorse the observations of the noble Baroness, Lady Robson. Teaching hospitals may well rue the day they go down that path.

Given the Government's well-known approach to research funding, it is perhaps not surprising that research has been summarily dispatched in two paragraphs, paragraphs 69 and 43, I believe. Moreover there has been no promise of a working document on medical research. Certainly we had an encouraging message earlier this afternoon from the noble Lord the Leader of the House, but I shall want to study his words before I comment further on his message to your Lordships' House.

In the longer run the health service is ultimately dependent on the quality of medical research and on teaching in the medical schools. Indeed we know that some radical developments are possible which will bring untold benefit to the people of this country within a decade, if adequate research funding is available. I wish to endorse the emphasis of the noble Lord, Lord Butterfield, on the central importance of operational research. The White Paper is silent on the special needs of medical schools. However, we are grateful to the noble Lord, Lord Dainton—who was supported by the noble Lords, Lord Flowers, Lord Brain, Lord Butterfield and Lord Hunter—for drawing attention to the special situation and needs of the medical schools. I am glad that the medical schools have friends in this particular court.

I was very conscious that the noble Lord, Lord Dainton, spoke with the authority of a former chairman of the University Grants Committee. He is, of course, the president of the Royal Postgraduate Medical School. I wish to be associated with the views of the four or five noble Lords who have drawn attention to the problems of medical schools. They have delivered a very convincing message to the Government. One can certainly see very clearly the need for a very carefully drafted financial memorandum between the Universities Funding Council, the university medical schools and the health authorities, and the need to establish clear procedures in order to determine accountability in that very complex situation. What assurances can the Minister give to the medical schools this evening? If he can give no assurances we shall have to return to the subject in the foreseeable future.

I shall now return to the White Paper and its radical and controversial proposals. It seems to me that the radical changes proposed in this paper differ from the reforms of the past 40 years at least in one crucial and major respect which has not been referred to. Unlike the reforms of the past these controversial reforms, unless they are modified, can disturb, undermine and change the relationship of trust which has existed between patient and doctor.

Some noble Lords, and in particular the medical Peers, will recall that it was the view of the late Lord Cohen of Birkenhead, a distinguished President of the General Medical Council, that the essence of the health transaction was to be found in the relationship between doctor and patient. That relationship was one of trust. That trust should not be undermined. That was his message. It seems to me that the structure offered in the White Paper, unless it is modified, could reject precisely what is most valuable in our health service heritage. Patients will begin to question whether the doctor is prescribing the best treatment to meet their condition or only the best treatment which the doctor's budget can afford.

If the Government are determined to go down the road signposted in the White Paper we urge them to pause and to allow more time for consultation. We urge them to see whether they have underestimated the problems, to see whether their solutions are feasible and to see whether unwittingly they may cause untold damage to that essential trust between doctor and patient. We say that the reforms should be based on full and careful examination of the proposals in the light of consultation. 'We also urge the Government to test the hypothesis in the paper in two or three areas of the country before they proceed to apply it and steamroller it through the country generally.

So, my Lords, I return to the point made at the beginning of the debate by the noble Lord, Lord Hunter of Newington, and my noble friend Lord Ennals.

9.11 p.m.

Lord Hesketh

My Lords, the first debate to which I replied in your Lordships' House was a debate initiated by the noble Lord, Lord Ennals. Not surprisingly it concerned the National Health Service. I remember that on that day there were many eminent noble Lords in your Lordships' House and I hoped that a little black hole might open up as I stood up to speak. It did not. I thought that this time I might feel rather differently, but I feel much the same. One thing I am sure of is that tomorrow's Hansard will make a substantial contribution to the process of consultation which is under way.

In his opening speech my noble friend Lord Belstead spoke of the need to achieve the highest possible quality of care for patients and to increase the responsiveness of the National Health Service to their needs. He also spoke about the improvements in management necessary to achieve those goals. Those twin themes have been central to our discussion today and are at the heart of the Government's proposals in the White Paper. I therefore make no apology for returning to them in my closing remarks.

The standards we expect from the National Health Service are high. Provision of care which is timely, appropriate and effective in an environment which is friendly, caring and efficient is easy to establish as a goal, but difficult to achieve in practice—as experience from many countries shows. The review of the National Health Service quite rightly looked at overseas experience in the delivery of health care but did not find, perhaps not surprisingly, any panacea. The standards which we are aiming for are not therefore derived from any external model. They are instead based on the best which the National Health Service already provides. I spoke of the challenge of providing high standards of service. That is a challenge to which many centres in the National Health Service rise munificently. Our aim in the White Paper is to identify the lessons of those successes and to make their excellence more widespread.

It would be invidious to single out any individual hospitals or doctors. I am sure that we can all think of excellent examples from our own experience, but perhaps I might highlight some areas of progress. First, the medical profession has made important steps in the development of medical audit systems to make doctors more aware of the results of their work. These developments have been pioneered by the individual Royal Colleges and have borne fruit in a number of innovative local schemes. Secondly, a number of health authorities have made determined efforts to improve the quality of personal service delivered to patients. Thirdly, many managers and clinicians have responded flexibly and imaginatively to the challenge of reducing waiting times.

Three factors link these examples. The first is that they are not "pie in the sky". They are all solid achievements, delivering real benefits now to National Health Service patients. The second is that the White Paper contains detailed proposals for action to make further progress on all of them. I want, however, to dwell on the third link, which is that progress on all of them depends on managers and doctors locally having the necessary authority, freedom and initiative to take action.

Delegation of authority is a central theme of the White Paper. Ministers can indicate the overall direction of policy in the NHS, but they cannot and should not seek to define in detail how the implementation of these policies is managed locally. Instead, our aim is the creation of a climate of initiative in which individual managers and doctors can take the necessary decisions at the right level. That is the best way to make sure that the benefits of management action reach the individual patient quickly and lead to real improvement where it matters most. This is starting to happen now and the White Paper aims to build on success by delegating authority further—in particular to individual hospitals and to individual doctors.

We should be clear what delegation of authority does not mean. First, it does not mean shirking of accountability by Ministers. Ministers remain fully answerable to Parliament for the spending of the large sums of taxpayers' money which are devoted to the National Health Service. But it makes no sense at all for detailed decisions about the running of individual hospitals and authorities to be sucked up to the centre. Such centralisaion means slower decision-making and that results in a poorer, less responsive service for patients.

Secondly, delegation of authority is certainly not a prelude to dismantling the National Health Service. All our reforms aim to strengthen the NHS within the current framework. We are seeking to remove those elements of the system that inhibit flexibility and responsiveness to the needs of patients. That process can only serve to strengthen the NHS overall.

This approach underlies the creation of the NHS hospital trusts and the self-governing hospitals that they will manage. The trusts will stand close to their local communities. They will have community membership, issue annual reports and hold annual meetings to report on their progress. They will be well placed to tap local pride and identification with the hospital. Their managers will also have greater freedom to respond to the needs of patients in the most appropriate way; indeed, they will have to do that if they are to win contracts. They will also have greater freedom to respond to the local labour market and to reward individual achievement and effort. This is a prescription for enterprise, initiative and enthusiasm within the National Health Service, not for its break-up. Nor is this a Government who are bent on centralising power.

We are also delegating power, responsibility and opportunity to individual general practitioners. GPs are closest to the individual patient, usually their main point of contact with the NHS. They are therefore best placed to identify patients' needs and respond to their wishes. The new, voluntary practice budget scheme will give GPs real opportunities to develop their own practice and to get the best deal for patients in their care. Of course, the details of the scheme will need careful discussion—the recently published working paper provides the basis for that—and participating practices will need support, for example, in the development of information systems. But the key to success will lie with the doctors who take part.

We firmly believe that giving doctors and managers more information about the costs of their work puts them in a better position to achieve maximum benefit from it. That explains the important proposals in the White Paper for tackling the wide variations in prescribing costs among general practitioners. It is remarkable that prescribing costs in some areas run at twice the level per head of population as in other areas. That cannot be helping the NHS as a whole to achieve the maximum benefit from the resources available. We shall therefore introduce a system of firm, realistic budgets for drug costs for each regional health authority and family practitioner committee. That will enable indicative budgets to he set for GP practices, so encouraging prudent prescribing by individual doctors. At each stage the budget set will reflect sensible and realistic assumptions about patients' needs, prescribing patterns and the introduction of new drugs. We have again published a working paper that sets out fuller details of how the scheme will operate and also explains how savings can be reinvested in other areas of primary health care.

Let me make one point perfectly clear. The drug budget scheme will not in any circumstances mean that patients will fail to get the treatment that they need. The budgets will be realistic and individual patients will continue to receive all the treatment that they need for as long as they need it. The scheme will have sufficient flexibility to cope with unforeseen circumstances—such as, say, a flu epidemic—as they arise, and good management of the scheme by the family practitioner committees should ensure that any difficulties are identified and addressed quickly. This is the right formula for the effective use of medicines in the National Health Service in the future.

Several of your Lordships, including the noble Lords, Lord Hunter, Lord Winstanley, Lord Nugent and Lord Rea, to name but a few, felt that the timescale was too compressed. My noble friend the Leader of the House acknowledged that the Government are setting themselves and the service a challenging timetable but we believe the timetable to be entirely realistic. Many of the reforms do not begin to take effect until April 1991. Some of the most important, such as self-governing hospitals and GP practice budgets, will grow and develop over a period of years. In the meantime it is most important to maintain the momentum of change and not to allow reform in the interests of patients to be bogged down by unnecessary delay—which is why we need dates.

Perhaps I may give an example. Earlier this afternoon the noble Lord, Lord Winstanley, referred to today's date, and today's debate and the arrival of the working papers in a way that shows why it is important to have dates.

Noble Lords opposite, and in particular the noble Lord, Lord Ennals, referred to an accountant's dream and had a not particularly happy view about the influence or interference of management. To refer to the Government's proposals as bringing a bonanza for accountants is not quite true. I agree with my noble friends Lady Gardner of Parkes, Lord Trafford and Lord Mottistone that the application of business principles to a service which will be spending £26 billion next year is not something for which one should apologise. The National Health Service needs investment in modern management. The Government will ensure that that investment takes place. One has only to think that an improvement or saving of 1 per cent. on that budget is the equivalent of another £260 million available to the health service. That is why we need good management in the NHS.

Many noble Lords, including the noble Lords, Lord Hunter, Lord Dainton, Lord Richardson, Lord Flowers, Lord Butterfield and Lord Auckland, discussed medical research and education. In fact I think that more noble Lords spoke on this topic than on any other subject. I have taken note of the points raised by a number of noble Lords concerning medical research and education. I can assure noble Lords that the Government are fully committed to maintaining the highest standards in connection with both.

My honourable friend the Under-Secretary of State, in a letter of 16th February to the noble Lord, Lord Nelson, said that the Government were carefully considering the import of the White Paper proposals on the response they wished to make to the report on priorities in medical research published by the sub-committee of the Science and Technology Select Committee of your Lordships' House.

As was said in that letter we hope to be able to set a firm date for publication in the next few weeks. With regard to medical education, the steering group on medical and dental education, which contains representatives of the major bodies with interest in undergraduate, medical and dental education, is currently considering how to improve the present arrangements for such education and will make its recommendations in the light of the White Paper proposals. I do not believe that it would be right for me to pre-empt this expert body.

Finally, I should like to thank the noble Lords, Lord Flowers and Lord Dainton, for their helpful suggestions. I can assure them that they will be fully considered.

The noble Lords, Lord Hayter and Lord Brain, both mentioned management training for doctors. I agree with the noble Lord, Lord Hayter, that the education of doctors will need to cover the principles of management, given their substantial responsibilities for resources. This must make sense. I understand that the profession is already making progress in this field. We shall encourage this trend and ensure that the necessary facilities are available. GPs and other doctors will need support if they are to use resources to the best effect; the Government recognise that too.

The noble Lords, Lord Ennals, Lord Bruce of Donington and Lord Stallard, suggested that we are in the business of breaking up the National Health Service. Perhaps I may underline the point made so eloquently by my noble friend Lord Trafford that no hospital will be forced to become self-governing. No GP will be forced to hold a budget for buying hospital and other services. These schemes are totally voluntary and all these hospitals and GPs will remain within the National Health Service.

I come now to the subject which I think I am correct in saying was the second most frequently mentioned after medical education: that is, the matter of community care. It was brought to your Lordships' attention by the noble Baronesses, Lady Seear and Lady Robson, and by the noble Lord, Lord Seebohm. The review of the National Health Service has focused closely on the funding and management of health services, hospitals and family doctors in particular. The Government fully recognise that the interaction of health and social care in the field of community care, including the relationship between health and personal social services, needs further study. That work is well in hand and Sir Roy Griffiths' report and the debate it has stimulated are central to that duty. I cannot give your Lordships a precise indication of when the work will be complete but it will not be unduly delayed. I can assure the House that the Government's policy objectives for what used to be called the "Cinderella" services remain unchanged.

The noble Lord, Lord Nugent, drew your Lordships' attention to an article in Marxism Today, a journal not often quoted in support of the Government's intentions. In that article, under the headline: Kenneth Clarke: Far-reaching and imaginative proposals", we see this: The programme seeks to preserve the basic principles on which the National Health Service was founded and to tackle its weaknesses through a series of incremental and imaginative reforms. Even they do not support the contention which is held by the noble Lords, Lord Bruce and Lord Ennals, opposite—

Lord Bruce of Donington

My Lords, has the noble Lord become converted to Marxism or something?

Lord Hesketh

My Lords, it may come as a surprise to the noble Lord, Lord Bruce, but the road to Damascus has not yet been crossed by me. I was interested that Marxism Today appears to support the government intention—

A noble Lord

So what?

A noble Lord

You are Marxist!

Lord Hesketh

—and that intention is the preservation of the National Health Service and the improvement of that service.

I was very grateful to the noble Earl, Lord Halsbury, for sending me some notes on the White Paper's use of the word "responsibility". Without necessarily accepting that the White Paper is, as the noble Earl suggests, managerially illiterate, I can assure him that his points will be taken into account in the implementation of the White Paper's proposals, including the preparation of legislation. I hope that his remarks will instil some scholarship into the department.

My noble friends Lord Gisborough and Lord Mottistone both drew to your Lordships' attention how the White Paper affects rural areas and the Isle of Wight. Clearly there are differences and different problems, to which we must address ourselves. I shall certainly transmit the points they have made to the department.

The noble Lords, Lord Rea and Lord Brain, drew your Lordships' attention to the proposed increase in the number of consultants. The noble Lord, Lord Rea, said that the total increase should be more and the noble Lord, Lord Brain, inquired whether the figures represented sessions or people. I can assure your Lordships that they are consultant doctors, whole and complete.

The noble Lord, Lord Carter, and the noble Baroness, Lady Masham, drew our attention to self-governing hospitals. The scope available to enable hospitals to become self governing, I can assure your Lordships, leaves unaffected every health authority's responsibility to ensure that a comprehensive range of services is available to people living within its boundaries. If a patient needs treatment at more than one hospital, he or she will receive it just as now.

The noble Lord, Lord Prys-Davies, referred to the patient's choice of hospital. Your Lordships will understand that contractual funding arrangements are necessary if money is to follow the patient and hospitals are to have a reasonably secure basis on which to budget. GP practices with their own budgets, and district health authorities for patients and services outside the practice budget scheme, will both be expected to keep funds in reserve to pay for referals to hospitals which are not covered by a contract. Paragraphs 4.24 and 6.12 of the White Paper make that clear.

The noble Baroness, Lady Robson of Kiddington, asked about the protection of core services. I hope that I can reassure the noble Baroness that the Government's proposals for self-governing hospitals will not jeopardise core services. They will remain dependent primarily on district health authorities for the bulk of their income. If more or better core services are what districts wish to purchase, hospital trusts will have to respond if they are not to find that that income is going elsewhere.

The noble Lord, Lord Carter, and the noble Baroness, Lady Masham of Ilton, made a number of important specific points, and the noble Lord, Lord Carter, raised some points of detail. With your Lordships' agreement I shall write to the noble Lords about the points raised, at the same time very much taking on board the point of the noble Baroness in regard to the letter that unfortunately she received only today. I shall ensure that any other specific questions that I may have missed are dealt with in the correspondence and that the contributions of all noble Lords to the debate are taken fully into account in our further work.

The Government are convinced that this framework of increased legislation and incentives at the local level is the right prescription for the future of the NHS. At its best the NHS has already displayed its ability to deliver high quality care through high quality management, so we are not borrowing ill-fitted solutions from other countries or even from the private sector. Our aim is to bring the whole of the NHS up to the high standards of the NHS at its best. This is an aim in which we can all share. I believe that the Government's proposals for reform put us on the road to achieving it.

Lord Hunter of Newington

My Lords, the House would wish me to thank the noble Lord the Leader of the House for opening the debate in the persuasive way that he did and to thank the noble Lord, Lord Hesketh, for the vigorous statement that he has made. In many ways I think that the House is reassured by what we have been told.

Inevitably, as one would expect, people will be watching the Government with the greatest attention in the coming weeks. One hopes that it may be possible to have a further debate in government time if that appears necessary.

I thank all noble Lords for taking part in the debate. I beg leave to withdraw the Motion for Papers.

Motion for Papers, by leave, withdrawn.

House adjourned at twenty-seven minutes before ten o'clock.