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Health and Care in the Community

Volume 688: debated on Thursday 25 January 2007

rose to call attention to health and care in the community; and to move for Papers.

The noble Baroness said: My Lords, I am pleased to have the opportunity of opening this debate today. The wording of the subject is deliberately wide as “health and care” encompasses a vast part of all our lives. I thank those who are to speak in this debate and who have particular experience and expertise from which we can all benefit.

When I checked the dictionary for the definition of “health”, “care” and “community”, I decided that each of these means much more now than the definitions given, especially “health”. One cannot pick up any newspaper or magazine without finding some new angle on “health”. Fitness and health are often taken to be the same thing, but this is not so. A person can be healthy but unfit, or unhealthy but still fairly fit. Recently, a speaker at the Royal College of Physicians referred to “the ill and the worried well” and I thought that that accurately reflected part of society.

In spite of constant advice to modify our habits or diets, the majority of people think more about health when they suffer some setback. The young have always believed they are immortal. The old are only too aware of their mortality and the ageing process. There is constantly published conflicting advice about the food to eat, exercise to take and the lifestyle to follow. Even those who just take everything for granted and never give a thought to health expect immediate National Health Service care and attention to be available at the moment of crisis, and usually it is.

Chronic conditions are something that people have to live with, often over very long periods and at home rather than in any medical facility. This is where the major problem arises. Many face the living bereavement of loved ones suffering from Alzheimer’s disease or senile dementia. Others have children with special needs requiring a lifetime of care. There are so many different situations.

The dividing line between health and care is creating a huge gulf in services. Social care is provided by local authorities and can be simple or complex, depending on the needs of the individual. The noble Lord, Lord Bruce-Lockhart, introduced a very good debate in this Chamber on adult social care, particularly the local government aspect of it, on 7 December. I do not intend to use this short time to repeat that debate, but commend it to those who have not read it.

The Department of Health, too, covers social care. If the words “social care” were included in the title of that department, it might be recognition of the importance of the issue.

There is need for much closer liaison between the fully funded NHS care and the social care in the community that is often available only at a cost to the patient. Local authorities face a double budget difficulty with an increasing load being transferred to home care from the NHS and a restriction on increasing their council tax. Is it surprising that we constantly read reports and hear anecdotal evidence of social services being less available and more restrictive conditions being applied, so that only the most critical cases now meet the eligibility criteria for free personal care?

The differentiation of treatment between NHS and social services has always been controversial. It is a great pity that more was not done by the Government in recent years to bridge that divide. It would have been easier to make changes when the Government were pouring money into the NHS—sadly, without result. Until joint working of health and care is established, those problems will continue. The NHS is keen to send patients home at the earliest possible date, but someone has to deal with the continuing burden—and that area lacks clarity. If the patient requires continuing health treatment at home, that is funded by the state; if their rehabilitation is classified as social need, they are not covered in the same way.

At a senior management level, there are joint committees and there is some joint working and planning of NHS and social care; but there is need for partnerships to extend that down to the everyday working level. There should be joint NHS and personal care for people, whatever their needs. Where do you draw the line between health and care in the community? What exactly does “personal care” mean?

I look forward to hearing from other noble Lords who intend to speak about vital issues such as child services, respite care, terminal care and the hospice movement, and care at home to keep people out of hospitals. In addition to the many social workers employed by the councils, it is estimated that some 5 million people provide care informally. No matter how much care is provided officially, the greatest amount of caring is done by relatives and friends who give their time to that dedicated service. Often, those carers are themselves reduced to a state of ill health by their great efforts. The whole community owes them a debt of gratitude.

My noble friend and colleague in dentistry Lord Colwyn had hoped to be able to put the case for NHS dental services to be readily available to all. Unfortunately, he is operating today and cannot be here. It should be remembered that dentistry is not a free service for any but the priority classes, but it remains far from being available and accessible for all, in spite of the Prime Minister’s promise to the contrary.

When I was a local authority chairman of social services, long before Ken and his freedom pass, we introduced free travel passes for retired people. We realised that keeping our older residents active and mobile was one of the best forms of social care and meant that those people were very much part of the community—not isolated at home, perhaps seeing no one except the person delivering meals on wheels. Human contact is essential to keep people going and many voluntary organisations play an important part in that process.

For some years, I was on the advisory committee of RSVP, the retired senior volunteer programme—part of Community Service Volunteers. By involving the retired in helping others, volunteers not only provided much-needed assistance, but were given an important and demanding role from which they benefited themselves. I recall a retired bus driver who was helping a young person on a one-to-one basis; he was delighted to have achieved a result in a field outside his own qualifications and he went on to help others in the same way. Others shopped, read and provided company—the needs were almost unlimited. The work continues and many voluntary organisations do a great deal to help people.

In December, the joint report of the All-Party Group on Primary Care and Public Health and the All-Party Group on Social Care considered that there was a need to reconfigure existing provision and resources to achieve the increase in preventive health and social care envisaged in the Wanless report. As one of the signatories to that all-party group report, I took full part in the meetings and hearings of evidence on which it was based.

The report concluded that current funding was insufficient to meet present and predicted demographic pressures and that because the charge for domiciliary social care is—to put it mildly—unpopular with service users, it acts as a deterrent from using such services if the user has to pay. That often leads to earlier use of more expensive institutional care. In considering the best use of public money and the best way to provide services, it is important that the overall long-term costs and benefits are assessed.

We know that the Government plan to have more NHS treatment centres available in the community, which should be good—but only if those centres are up and running before the same services in the hospitals are closed. At the outset, that might be more costly as the services will need to be run in parallel during an overlap period, to establish the changeover. The savings would follow.

In London, many patients choose not to have a GP. They rely on going to the nearest A&E when they have a health problem, which clogs up those important emergency services. It would be better if those patients were able to go to a community treatment centre. It will, however, remain essential to have additional major trauma centres.

On funding, the all-party group recommended:

“2.1 The Comprehensive Spending Review (CSR) must acknowledge and make provision for the demographic pressures on Local Authority and NHS care and training budgets reflecting growing numbers of disabled children and young people with complex needs, adults with multiple disabilities suffering social exclusion, and the sharp rise in older people with combinations of physical, sensory and intellectual impairments.

2.2 The CSR should make provision for new money to address the issue of health inequalities and the need for training and development of the work force in their new role.

2.3 Government should take further steps to promote maximum flexibility in the use of resources, including wider opportunities for pooled budgets, greater financial and decision-making delegation to front-line staff and people using services, schemes to combine statutory and community resources, and safeguards against cost-shunting.

2.4 The rationale for and impact of charging for domiciliary care should be rigorously re-examined. A public debate on funding for social care might help to explore alternative solutions”.

Many other matters were considered by the all-party group, such as the need for change from the culture of dependency, with patients taking more responsibility for their own health, particularly in preventive terms.

I have been involved in the NHS as a dentist and on the administrative side for many years, serving on area and regional health authorities and as an NHS trust chairman. Each time that the NHS seemed to be just settling down, it was re-organised, which was damaging to morale and usually financially wasteful. Nevertheless, I am suggesting further changes now. This is because social services and personal care are each essential parts of a complete healthcare system, and it is time that each human being’s treatment was considered as for the whole person.

That takes me to exactly 12 minutes, the time which I was to have. However, I have been told that I have three minutes more. As a result, I will just quote from a letter that I received from the General Social Care Council on arriving in the House this afternoon. I was particularly pleased to have this and to realise how standards are improving and that there is a register. Social workers have always deserved such a degree of recognition. What also pleased me, in view of my comments, was that the General Social Care Council,

“realizes the importance of practitioners working together across the whole range of professional specialisms in health and social care to make joined-up services a reality for service users”.

That summarises the whole thing. I beg to move for Papers.

My Lords, it is always a great pleasure to follow the noble Baroness, Lady Gardner of Parkes. I must say that I very much agree with her about the importance of social care. As an ex-director of social services, I could hardly say otherwise. I am glad that she tabled this Motion for debate today, because it provides me with an early opportunity to engage in a kind of mini-retrospective of my time as a health Minister. That was a job which had two parts to it: continuing the repair job, if I may put it that way, on the NHS that has been in progress since 1997; and taking forward the reforms that will enable the NHS and social care to cope with the challenges of the future.

Those challenges are formidable: rapidly changing medical technology; rising public expectations; and a set of demographic changes involving a considerable rise in the numbers of over-80s that will increase demands on health and social care. I heard quite a lot in my time as a Minister from the Benches opposite about the shortcomings of the Government's approach to the NHS, but I have not heard a great deal about their policies. From the noble Baroness, Lady Gardner of Parkes, I began to discern some emerging policies. Another reorganisation sounds interesting. This week, we also saw some green shoots from the other place, from the leader of the Opposition, who seems to want a return to GP fund holding and the dropping of all national targets. I will return to them in a moment.

First, I want briefly to refresh the memories of everyone on the Benches opposite on how they left the NHS in 1997, after running it for 18 years. It was an NHS short of doctors, nurses and virtually every other type of staff. Healthcare spending was at the bottom of the EU league at about 6 per cent of GDP. It is at 9 per cent now—about the EU average. There was a deficit in 1996-97 of 1.5 per cent of turnover, which is about twice what the very noisy deficit was at the end of last year. The buildings, plant and equipment were in a parlous state, reflecting the failure to invest. Perhaps worst of all were the scandalously long waiting lists, appalling conditions in many A&E departments and, if I may put it this way, unnecessary deaths from failure to invest adequately in cancer and coronary heart disease services. I do not want to dwell too much on that, but it is worth us remembering those things.

I acknowledge that not everything that the Government have done on the NHS is perfect, but we have invested. We have recruited many more staff and improved their pay and conditions of service. We have built literally dozens of new hospitals and hundreds of new GP and community facilities. We have also provided a whole new generation of modern equipment. We can point to that extra investment improving patient services.

If the leader of the Opposition thinks that the changes could have been achieved without some national targets, he is being managerially naive. If he believes that the Conservatives never resorted to national targets or objectives, he is badly briefed. I well remember how, as a health authority chairman under the Conservatives, we were interrogated quite vigorously about the 50 or more national priorities that the Government were running at the time. There was not much difference between those national priorities and targets.

I shall spend the rest of my time referring to the continuing changes that the NHS needs and that the Government have initiated to meet the challenges of the future. I spent much of my time in the past two years pushing on with those necessary changes and I am pleased that we have done so. My only regret is that we did not start some of them sooner. This is particularly the case with choice, an area we are now well and truly establishing. The public will insist that any future Government continue to pursue choice. It needs to be continually nurtured and promoted, against some professional resistance. We need to move choice into new areas, including end-of-life care and how we can leave this world with dignity, at a time and place of our choosing.

As a Government, we have put in place a commissioning framework involving a smaller number of eventually better skilled PCTs. Both Governments have been slower than they might have been on this issue, but we at least have grasped the nettle. I am particularly proud of our work in establishing practice-based commissioning. The GPs deserve great credit for embracing this idea. We will achieve virtually 100 per cent GP coverage with practice-based commissioning, compared to the 50 per cent coverage that GP fund holding achieved. It looks as if the leader of the Opposition wants to abandon this improvement and impose an arbitrary change of GP fund holding on the profession and the NHS.

Alongside commissioning and choice, we have done a lot to establish foundation trusts. By the beginning of 2008, we should have at least 100 of them, including many mental health trusts. There has been a great deal of effort to ensure that hospitals can achieve more autonomy from Whitehall. I do not have time to dwell on the other necessary modernising changes we have pursued, such as the national programme for IT or the important strategic White Paper on services outside hospitals, Our Health, Our Care, Our Say, which said much on strengthening integration of health and social care.

Finally, on competition and markets, the Conservatives deserve a great deal of credit for the way they introduced a mixed economy into community care in the early 1990s. I was pleased to be involved in that. Yet I fear they lost their nerve on this issue when it came to the NHS. It has taken a Labour Government to face up to the fact that the public is on the whole indifferent to whether they get their healthcare from the public, private or voluntary or social enterprise sectors. We have had the nerve to bring in plurality of providers, and a jolly good thing, too. We deserve the credit for carrying on with that policy—long may it continue.

The noble Lord mentioned that he thought it would be a good idea for patients to be able to leave this life at a time of their choosing. Could he clarify that? It sounded rather interesting.

I think in the coming months we will have plenty of time to expand on that particular subject.

My Lords, with so much having been placed on primary health care and the working hours GPs having been reduced, patients often do not seem to have the continuity of care that they used to from their GPs. As so many problems arise at night, on bank holidays and at weekends, patients have to rely on the out-of-hours doctors services. Prevention is vital in so many cases. Checking blood pressure and sugar levels is easy, but unless patients ask for it this often does not take place. I personally heard recently of several patients who were misdiagnosed by the GP and not sent for a scan. These involve serious conditions of cancer and brain tumours. GPs should be vigilant not evasive in these cases.

The correct procedure when people have strokes or heart attacks should be to get them to a centre of excellence, so that they can have a scan within three hours and, if appropriate, clot-busting therapy. Without scanners working 24-hour days seven days a week, this cannot happen. This is still a dream in some areas such as rural north Yorkshire, where I live.

There must be a reliable emergency ambulance service. Is the Minister aware of the concern over the 45-minute meal breaks for ambulance crews, which are statutory under EU law but are subject to local negotiations? As about 13 deaths have been attributed to meal breaks that cannot be disturbed—goodness knows how many near misses there have been—I hope that the Minister will take up this challenge, particularly from the Scottish border to north Yorkshire.

In the interests of patient safety, there is concern that the posts of specialist nurses for long-term medical conditions such as stoma care, diabetes, epilepsy, MS, strokes, Parkinson’s disease, motor neurone disease and many others are being cut or not replaced when they become vacant, and that skilled nurses are being put on to general ward duties. This will be economically disastrous, as these nurses are the vital link between the specialist hospital unit and the community. They give support to the patients and their carers. They monitor medication and equipment, and they support and train district nurses. Because they are paid by the hospitals, if not by voluntary organisations, I hope that the Minister will be able to sort out this vital matter with the hospitals and PCTs. Perhaps there will have to be joint funding, otherwise patients will become neglected in the community and land up in hospital.

The North Yorkshire and York PCT has inherited debts of millions of pounds and has therefore made stringent cuts, delaying patient treatments and out-patient appointments. In the long run, I cannot see that this will benefit anyone. One of the silent cuts has been made to the wheelchair and equipment service. Two men deliver and collect these aids from and to patients’ homes in a wide rural area in the Harrogate district. A third man was employed to clean everything before it was reallocated. He has left, and the post has not been refilled, with the result that the equipment may not get a thorough cleaning. This is extremely dangerous, given infections such as C. difficile, which is very dangerous to vulnerable, disabled people.

In a prelude to my Question on 8 February, I feel I should alert your Lordships to the growing anxiety about forms of community-associated MRSA—CA-MRSA—which are easy to spread. PVL—Panton-Valentine leukocidin—destroys the white cells that the body uses to defend itself. Because it can infect young people who are not expected to become ill, the infection is often not identified quickly enough to treat. High-risk groups are participants in close contact such as sports clubs, the military, residential homes and children’s playgrounds. There should be regular bathing, showering, hand washing, and changes of linen and underwear, and sharing personal items such as toothbrushes, face cloths and towels should be avoided. Wounds should be covered.

Fast NHS tests are needed that can track the spread of the disease from the community to infecting vulnerable people. Existing methods take more than two weeks to detect the organism, when it can kill within a day. In Texas, bacteria with the PVL genes continue to spread. They have risen to affect 10 per cent of all children in three years and cause symptoms ranging from pimples and boils to flesh-dissolving disease and the killer, pneumonia.

In the USA, the incidence of CA-MRSA is screened nationally, and in Scotland there is a system of identifying all MRSA strains. Surely, with such risks, we should have rigorous surveillance and screening for CA-MRSA in the community. I hope that the Government will push this forward with the expertise of the Health Protection Agency. I thank the noble Baroness, Lady Gardner of Parkes, for securing this very important debate.

My Lords, I, too, congratulate my noble friend Lady Gardner of Parkes on the excellent way in which she has initiated this debate. As ever, she has brought to bear on these matters her first-hand experience of many long years. In the excellent debate last week on the social care workforce, which was initiated by the noble Earl, Lord Listowel, all speakers rightly congratulated the Government on making more funds available for the NHS. They also spoke warmly of the many policy frameworks that have been provided for community care.

However, last week, as today, we were obliged to confront the gulf between what has been provided and what people are experiencing at grass-roots level. I have no doubt that we will hear from the Minister—he would be right so to say—that funding for the NHS has increased from around £34 billion in 1997-98 to around £78 billion in 2005-06; that will save him a bit of time. We will also hear, correctly, that there have been real improvements in certain health outcomes, including a reduction in waiting lists and better facilities for patients, which are entirely welcome. But those of us whose reading includes the regional press—I assume that that does not include the noble Lord, Lord Warner—cannot have failed to notice the weekly, sometimes daily, stories about cuts, closures and crises in the NHS, which, if only partly accurate, are puzzling when set against government statistics. Sadly, these cuts, closures and crises more often than not affect community care. So what is going wrong?

In its report published last December on NHS deficits, the Health Select Committee in another place went some way towards providing the answer. The report points out that the overall NHS deficit has increased over the past two years, partly because of funding formulae, but also because of,

“poor central and poor local management”.

It says that government estimates of costs for, for example, Agenda for Change and doctors’ contracts,

“proved to be hopelessly unrealistic”,

which is a point apparently now accepted by Patricia Hewitt. The report adds that repeated policy changes imposed by the Government at short notice have contributed to the problem. Poor local management is also blamed. The extraordinary saga of the creation of a multiplicity of primary care trusts on the ground of improved local delivery, only for that decision to be reversed two years later, illustrates the problem.

My Lords, does the noble Baroness then accept that, if the deficit in 1996-97 was twice the deficit of last year, the previous Government were twice as culpable as this Government in the way they ran the NHS?

My Lords, I thought that I would tempt the noble Lord from his lair. Perhaps he would like to continue to listen to my remarks—and I claim injury time.

The situation of the NHS in Norfolk also illustrates the problem. We are told that Norfolk PCTs account for £50 million of the overall NHS deficit. I do not see how this can be. I do not know what kind of management at national and/or local level can have incurred such a debt in one county that serves only 750,000 people. But, more seriously, what are the consequences of making good such a debt on health services in Norfolk? The only certain thing is that the people of Norfolk have to suffer reductions in service through no fault of their own. The impact of meeting these deficits is projected to be dire.

Norfolk has nine community hospitals, which, as always, are much loved, supported and used. They provide a range of services, as well as, in most cases, a halfway house for patients being discharged, often after serious surgery. All these hospitals are being considered for closure or a reduction in the number of beds. I can describe these plans only, in the words of Sir Humphrey, as “Very courageous, Minister”, because they are not very popular. Earlier last year, I seem to recall, there were headlines about a £750 million windfall to develop community hospitals. What happened to the windfall? According to local health chiefs, the emphasis is to shift to treatment at home.

I can only ask the Minister, who is greatly respected and admired in this House for his knowledge in these matters, to look at the reality of care at home in a rural area. Who is to provide and deliver that care? How stretched is domiciliary care already? What are the travelling times and costs? Is it realistic to provide, say, physiotherapy in the home, where travelling times between patients could be up to an hour? I am quite sure that he understands these matters and is considering them.

Last week, we learnt that there are to be drastic cuts in the out-of-hours GP service across Norfolk—again, in an effort to meet the £50 million deficit. The number of bases manned between midnight and 8 am is to be cut from 11 to six, to meet demands for reductions from the PCT. Local GPs believe that the reductions will put patients at risk in such a large and thinly populated county. GPs are the cornerstone of community care. These cuts are bad news for worried and vulnerable people who have to use the service out of hours. A&E will have to try to take the strain and so will families and carers. Social services will certainly not be able to help. As Dame Denise Platt points out in her second report on the state of social care, there is a gap between what the Government want to do and what is actually happening in people’s experience.

I have perhaps been unduly critical and gloomy. I recognise that the Government have been serious in their intention to put more resources into healthcare; indeed, they have done so. But, as Camilla Cavendish says in the Times today,

“Money should never have been seen as a substitute for management”.

I share the bewilderment of patients and their families, who are hearing one thing and experiencing another. I hope that today the Minister, drawing on his own extensive experience, will have some words of comfort.

My Lords, I, too, add my name to the long list of those giving deserved congratulations to the noble Baroness, Lady Gardner of Parkes, but I hasten to add that I must disagree that the National Health Service needs more structural reform. I will say why a bit later.

In the last debate on the National Health Service in your Lordships’ House, I declared an interest as both consumer and stakeholder. I make no apologies for doing so again. Speaking today as a service user, I want to get away from the lofty heights of budgets and macro-numbers in respect of National Health Service provisions. We already know that investment in the National Health Service has doubled, that there are over 300,000 additional staff since 1997 and that waiting times have been reduced in many areas of clinical care.

I want to talk today more about the principles that should underpin the current NHS reforms—the reform programme that the Government call “Care Closer to Home”. As a user, I welcome the objective behind the Government’s proposals, which aim to provide a flexible, integrated and responsive health service, based on the community and built around the needs of the community. At the same time, there must be a recognition that our healthcare depends equally on our social care. I hope that, in the reform programme, the Government will ensure that a wide range of social care services, working with health services, is available in what is popularly called the one-stop care shop.

The White Paper quite properly refers to preventive services. Preventive services ensure that an assessment is made of people’s lifestyles so that they themselves can be mindful of the risks. The White Paper is encouraging on the issue of self-care. So the continuing challenge for the Government is to tackle inequality and, as part of social care, to ensure that they also attack the roots of poverty. We all know that if you live in poor housing, if your diet is poor and if you are among the long-term unemployed, your medical needs are likely to be that much greater. The Government and our care services must deal with the effects of these problems, but individuals can also make a contribution by dealing with the causes.

The significance of the next step in the reform agenda for the National Health Service is that services are required to be carried out within a framework of certain basic principles. I want to suggest one or two principles that I feel are necessary. Reform should be based on need and not driven solely on the basis of cost. In other words, what counts is what is best for patients. Treatment must remain free at the point of use. We cannot adopt the practices prevalent in some countries where your credit rating is checked before your pulse. There must be equality of access and universal coverage. Ours is a national health service, open to all and with care for all. Local services should be designed by and with local communities, but national standards should also apply. The next round of reform must also end the postcode lottery in respect of health access and provision. As a fundamental principle, there should be more collaboration in healthcare and less competition.

The best patient care is delivered when all service providers work in partnership and share best practice. The Royal College of Nursing has called for binding contractual obligations, requiring organisations tendering for NHS services to develop co-operative partnerships. I support that aim. The NHS belongs to all of us, whether patients or providers. We all have an interest in its reform. So the NHS has many needs, but what it now requires above all else is a period of stability, with continuity of policies. As we speak, there is a great danger that the NHS will suffer from what I call policy indigestion, leading to structural instability.

To sum up, we must co-ordinate all our care services, including health. We must involve both consumers and stakeholders in the decision-making process. The NHS must remain the centrepiece of this country’s healthcare; public health and social justice depend on it. The staff of the National Health Service have played their part. They have adopted and are delivering Agenda for Change. If we now fail to secure a reformed NHS, we risk a return to the unhealthy, unequal country that was Britain before the NHS.

My Lords, it is some 40 years since I began my work with the Women’s Royal Voluntary Service in Leicestershire. At that time we provided a vast range of services to meet various needs in our local community. One of our busiest sections was responsible for working with older people. It included meals on wheels, clubs for the elderly, day centres, our work within hospitals and later the books on wheels scheme. All these provided support for people, enabling them to lead independent lives in their own homes for longer. I take this opportunity to place on record my thanks to all those people and to those who continue that work today.

Here we are today all these years later tackling some of the very same issues, but the major change is the increased longevity of many people. In 1971, 16 per cent of the UK’s population were over 65. By 2005, 6 per cent of the population were over 85, and the 2001 census showed that, for the first time, the number of people in England and Wales over 60 was greater than the number under 16. Therefore, the pressures we are facing to provide the services that we hope to provide are even more acute.

We should add to that the pressure on the NHS itself. The Department of Health expects a shortfall of 1,200 general practitioners in the coming years and the likely closure of a further 36 community hospitals, which I understand are under review, 10 having been closed since 1999.

I am very grateful to my noble friend Lady Gardner of Parkes for introducing this important debate. She and other speakers highlighted some of the important issues. I should like to pick up a crucial point that she made on pooled budgets and the possibility of shunting cost responsibility between health, social services and local authorities.

My noble friend Lady Shephard spoke of what happens on the ground. As your Lordships know, I have the great honour to be the Conservative Defra spokesman in this House. Therefore, I cover rural affairs and will address that subject today. Care provision is needed whether one lives in a town, a village or a remote hamlet. However, the cost of providing such cover is higher and more difficult to deliver in rural areas and in some cases is very fragmented. That is all the more reason to ensure that services are joined up. It is important that services should be provided in people’s own homes and that people living in their own homes are enabled to attend surgery and hospital appointments when necessary.

I am glad to tell the House that earlier this week an all-party group on rural services was established. One of the issues suggested for detailed consideration was that of health and social provision in rural areas. Members of the group recognise that such services can be successfully provided only by overcoming any barriers that exist between the NHS and social care services. If we add to that the contribution made by many families, friends and voluntary organisations, we realise that there is a big challenge ahead and that proper provision has to be established.

I fear that in some cases the care provided is not adequate. In an era of modern communications surely we should be able to connect healthcare, social care, the doctor’s surgery and other support services. It is much easier to do that than it was 40 years ago. As my right honourable friend David Cameron said in a recent speech to Age Concern:

“We want to see more joint commissioning of both health and social care services acting together for the benefit of both the cared-for and their carers, rather than in opposition to each other, as so often they do today”.

Like the noble Lord, Lord Morris, I looked at the health White Paper. I should like to draw two matters in particular to the Minister’s attention. One of the first observations it makes is that in placing new responsibilities on local authorities and the NHS to work together, adequate funding will be needed. I hope that the Minister will give us an assurance on funding when he replies to the debate. Secondly, the White Paper refers to offering support for carers, including improved emergency respite arrangements and the establishment of a national helpline for carers as one of its priorities. Thirdly, the White Paper states that extending direct payments and piloting of individual budgets for social care to allow people to decide what their allocations are spent on must be achieved through primary legislation. I was surprised by that and I seek clarification from the Minister as to when that will happen and whether it requires primary legislation.

All of us are acutely aware of the needs of some of our most vulnerable and elderly people and I hope that today’s debate will contribute to ensuring that on the ground that sort of support and encouragement will be achieved.

My Lords, I should like to deal with a very different aspect and that is the connection between unemployment and ill health. Many doctors have appreciated that those who lose their jobs often suffer ill health as a result. Indeed, many patients who suffer ill health might improve if only they were able to find employment suited to their special needs.

There was a fascinating experiment in 2001 which I should like briefly to describe to your Lordships. I am associated with the Tomorrow’s People charity, which specialises in helping the long-term unemployed into work. It has a brilliantly successful record in that regard. It appreciated that there were these patients who might be helped and this led to a liaison with the James Wigg general practice in north London whereby it was arranged that one of the advisers would go to the surgery on one day a week and offer to those who wished to avail themselves of it the package of employment support. In this case 200 people were seen and of those 61 agreed to go for the full package. As a result some found employment and others found voluntary work or went into training.

The results were evaluated in 2004 by an independent authority. It found that 36 per cent were in employment and 55 per cent went for training or voluntary work. But what was most interesting was the health outcome. There were 20 per cent fewer GP consultations from the 61, 74 per cent fewer referrals to other practice counsellors and 19 per cent fewer antidepressant prescriptions after people had been on board with the GP for 18 months.

This led to Tomorrow’s People wishing to expand the initiative and it now has advisers in about 80 surgeries across the country. There are some in the area with which I am particularly associated—Plymouth and Torbay—and I happen to know the adviser who acts for these GP surgeries. He is a remarkable man and has even got himself into the pain management clinic of Torbay hospital.

So it really works but it works because people are in an environment that they trust with doctors whom they trust and it is entirely voluntary. There is no pressure at all. The doctor may suggest to the patient that this would be useful and the patient can take it up or not. In some cases the patients learn about this through going to the surgery and seeing the adviser. I know that this has been sufficiently impressive for the Government to consider taking it up on a wider scale still through Jobcentre Plus. That sounds fine but I add a note of caution: one of the reasons for the success of Tomorrow’s People or any similar voluntary organisation is that the advisers are totally independent. Many patients are scared of the official approach. Jobcentre Plus advisers cannot be anything other than official; it is the nature of the case.

Furthermore, disturbing noises are coming from Ministers about trying to coerce people into seeking employment. In the very vulnerable sector with which we are dealing, that would be tantamount to disaster. It is essential that people decide themselves what they want to do. I trust that Ministers will bear that in mind if they really want to roll out this initiative on a much broader base.

There is much good in this approach. It has a very positive effect on people’s health. There is a clear financial aspect, because the more people go back to work, the less dependence there will be on benefits. There is disturbing information from the Department for Work and Pensions that when someone has been on benefits for, say, a year they are likely to be out of work for eight years, which could even take them to retirement age, meaning that they never work again. There is immense pressure, if one wants to save public money, to pursue this line. I am concerned, however, that this initiative should not fall into the hands of bureaucrats, who, however well intentioned, will not understand that its success depends on its voluntary, non-official nature and its advisers’ willingness to work one to one with individuals for as long as it takes.

Each session normally lasts from 45 minutes to an hour. Compare that with the average consultation with a GP or even a Jobcentre Plus worker and you will see how much time and effort is given. What is more, volunteers will carry on and on until the individual is in work or they have otherwise disposed of the case. It is a fascinating way of dealing with a long-term problem, and I hope that the Government will take it on board by funding some of these private initiatives rather than operating through Jobcentre Plus.

One of the things that restrains Tomorrow’s People is the difficulty of finding funds from hard-pressed GPs, who would be very happy to take up such work but simply do not have the funds so to do. I leave that thought with the Minister.

My Lords, this is a very welcome opportunity to debate our concerns, hopes and expectations for healthcare in the community. We must recall that this can be a meaningful debate only if we have the assured confident continuity of a securely financed National Health Service that can operate within its budget parameters and confidently provide accurate and wholly transparent financial assurances of its ability to do so.

When last we debated the National Health Service, on 7 December, I drew noble Lords’ attention to the apparent uncertainty and confusion about the precise deficit forecast by the service for the current year, according to the quarterly report that it had filed in our Library on 9 November. Following that debate, I wrote to Her Majesty’s Government requesting clarification of the precise deficit now forecast as the correct interpretation of the figures in the 9 November filing. The then Minister of State at the Department of Health, the noble Lord, Lord Warner, replied that the deficit forecast at quarter two for the National Health Service as a whole was £94 million, after the application of a £350 million contingency established by the strategic health authorities. I think that it was implied that they had been applied in the current financial year, which is a very important point. I was extremely grateful to the noble Lord, Lord Warner, for his reply, which was extremely helpful and commendably prompt. I found it less than wholly clear on a possible second £350 million contingency that was referred to in the same sentence, and it was not clear whether there were two separate contingencies of £350 million or one, and how many of those had been applied to arrive at the £94 million deficiency.

I am afraid that I submitted a further six Questions for Written Answer to the Government, each dealing with a very specific aspect of the same deficit forecast for the National Health Service this year. Those Questions were tabled on 9 January 2007. I anticipated a reply within the normal 14-day term, by 23 January 2007. I may have overlooked one of the many rules that I have had to learn on arriving in this House; perhaps a novice Peer is not entitled to a reply within 14 days. I am still waiting on those Answers. At present, none of the replies has come in, so I am talking today without the knowledge of what will be the result.

Without boring your Lordships with the detail of the six Questions, I summarise by saying that each of them was concerned with how far the £94 million currently forecast deficit already took account of any provisions or contingencies that had been previously made by the National Health Service in setting its internal budgets for the current year, and what precisely might be the value of any such provisions and contingencies still remaining, which could be included later to adjust any further adverse variance which might be suffered by the NHS in the balance of the current year.

My curiosity about these figures was particularly acute because the noble Lord, Lord Warner, in his helpful reply, had recognised that the £94 million forecast deficit was after the application of the £350 million contingency. That raised in my mind the possibility that this might mean that the real running rate of cash deficiency—if we were in fact talking about a cash deficiency for the current year—was actually the sum total of those two figures at £444 million, or perhaps even £794 million, if the sum of the other £350 million mentioned by the noble Lord, Lord Warner, as apparently a second contingency, was also already written back. This question does, however, raise the issue of what precisely the deficit that we are seeking to quantify actually constitutes.

What I am trying to get to here—and I can find no record anywhere in government reports to assist me—is the net cash cost of running the National Health Service for each year, and then to compare how that net cash cost, stripped of all confusions caused by contingencies and provisions, compares from one year to another. If we can once get to the definitive net cash deficit for the NHS, then we shall have an accurate account at last of how far the NHS is performing within central government’s overall budget plan, and whether there is in fact a black hole for the current year, which will carry on as a reflection of operating net deficit, which will need to be filled by incremental funding from the public purse, from the taxpayers’ pocket, for the next financial year. Alternatively, there will need to be significant further reductions in NHS services to compensate, thus reducing the value of the health service that the taxpayers hope and believe they are paying for.

The Secretary of State was quoted by the BBC on 21 November 2006 as stating that she would take “personal responsibility” to restore the National Health Service “to financial balance” by the end of March 2007. Unfortunately, what the Secretary of State did not say was how the NHS will define the winning post for achieving a “financial balance” at the end of March 2007. Do the Government intend, as probably they should, that this represents the balance of cash spent compared to cash allocated in accordance with the Government’s budget for health for the whole year, or do they have some alternative scheme whereby they intend to judge themselves on a performance based on what would effectively represent the trading account for a conventional corporate entity—no loss/no profit—which may be significantly distorted by the release and offset of contingencies and provisions on the lines that I have stated?

My very strong belief is that all uncertainty should be removed now from this important issue, so that we may know precisely what figure will reliably show when the NHS budget is “in balance” and how that figure is quantified and defined by the NHS financial control arm. It is on the record as stating that 56 trusts and 119 primary care trusts are currently in deficit. I suggest that the accountants for the National Health Service must have discovered the holy grail of accounting if they can absorb 175 quasi-subsidiaries in deficit and still be in balance at year end. In which case, I shall bow my head in humble admiration of their brilliant accounting techniques.

My Lords, this is an opportune debate and I am grateful to my noble friend Lady Gardner of Parkes for initiating it. It comes when many community hospitals are threatened with closure, as PCTs struggle with debt, and when social care, whether in care homes or in the community, is subject to huge budgetary pressures. Earlier this week we heard from the LGA, and how the service is in danger of imploding through lack of adequate funding. Recently, I spoke in a debate on the pressures that exist in the social service budget of Lincolnshire County Council. Suffice it to say that the Government cannot expect councils to meet demographic changes and provide for increasing care needs without adequate funding.

I want to speak about community hospitals. A paradox is that the threat of closure comes when the Secretary of State is talking about building new ones. I join the debate to talk to the House about the opportunity that I believe exists and which suggests itself as a result of my direct experience of a small local community hospital, looking at things from the other end of the telescope from my noble friend Lord James of Blackheath.

I declare an interest as I remain a trustee of the hospital in Holbeach of which I was chairman for 18 years until last September. Time means that I must précis the story, but in 1988 when it became clear that Holbeach Hospital was to be closed, the South Lincolnshire Health Authority, as it was then, faced a budget cut consequent on RAWP, which some noble Lords will remember as the Resources Allocation Working Party. Rightly there was an outcry. Our nearest district general hospital was over 20 miles away. A group of us sought to set up a new model, which to the credit of the health authority was accepted and continues to flourish to this day.

We formed a community-based charitable trust and, backed by councils at county, district and parish level, we raised funds from local organisations and people. Converting the open wards to 26 nursing-home beds, we occupied them with many of the original long-term-stay patients. The hospital had very much been a geriatric long-term-stay institution. At that time the social security budget funded their care. The majority, with the exception of a few self-funders, are now social-services funded, of course. We also contracted with the health authority to provide six doctors’ beds and continued the out-patients’ clinics, including the physiotherapist clinic. The net result was an improved facility, running at an overall budget of half that which had been allowed by the health authority.

It has been an interesting adventure and not without incident, but the outcome has been remarkable. The trust benefited from a legacy which enabled it to extend the building and further improve facilities. From the original 26 beds, we now have 37 care beds offering different degrees of nursing care. The six doctors’ beds are now nine and they are used for terminal, respite and intermediate care. The out-patients’ facilities have been increased, so that out-patient clinics, the services of our part-time physiotherapist plus the nine beds are now provided in this current year to the NHS for £273,000. The Minister will know that that is remarkable value for money for the NHS.

We are optimistic that practice commissioning will provide additional opportunities for us. We already run phlebotomy clinics for the local doctors. Above all, we have preserved a local resource which is locally seen to be an important part of our community’s life. A recent local fundraising campaign means that we are on the verge of buying the residual freehold from the NHS, thus saving the rent that we have been paying.

Your Lordships may consider me a little overweight with this subject. I certainly manifest the symptoms of excessive enthusiasm for my own ideas; that can be a fatal condition in a political speaker. However, I hope that it may prove infectious in this case. What better way has central government of keeping health resources at local level than trusting local people to run them on a voluntary basis? With imagination, closures can be averted. Valuable community resources can be maintained. Government can build on the local support—indeed, affection—of what people rightly consider to be their hospital.

My Lords, I am most grateful to my noble friend Lady Gardner of Parkes for allowing me the opportunity of indulging what has become a hobby. As my noble friend Lord Howe knows, I have been able to get interested in health over only the past two years, an interest created by its problems and opportunities. I have also admired the dogmatic approach of the noble Lord, Lord Warner, and his confidence in what he has done, for which I thank him. He is a good servant of the health service.

If I were to speak in the noble Lord’s words, I would remind your Lordships that we have the biggest and most expensive hospital-building programme in Europe, and our doctors and consultants are the highest paid. We have more employees in the health service per head of population than any other country in Europe. We are advanced in drug development and certain research. We also have great demand and the greatest waiting lists for our hospitals and trusts in Europe.

Last time, I asked the government Front Bench if they could answer a simple question. I spoke about waiting times, and pointed out that, in general, it was roughly another 43 days after you had seen a doctor before you saw a consultant. I said that I would table a Question for Written Answer, and 43 days later I am just about expecting a response. I asked the Government,

“what is the average time it now takes for citizens to—

(a) see their general practitioner (GP);

(b) see a consultant, upon referral by the GP, by way of the ‘choose and book’ system;

(c) obtain an appointment for a diagnostic procedure, for example, an MRI scan, a CT scan or a blood test, upon referral by a consultant;

(d) obtain a follow-up appointment with the consultant to discuss the results of the diagnostic procedure; and

(e) enter hospital for the appropriate surgery or treatment”.

I would appreciate it if I could have an answer within 47 days.

Health has become a hobby of mine because I am handicapped by my own advantages. I do not think I have spent a day in bed in my life. I have certainly never spent a night in hospital. I have been and worked in some of the more difficult and deadly parts of the world, where my body seems instantly to reject every foreign body; I could well be an appointed taster to some of the crowned heads of the world. In these areas, we were always provided with packs containing syringes and instructions. There would be moments where one needed to use morphine, and the pack would say, in badly translated English, “Get the posterior of the patient in a bent position, advance and stab him viciously”. I looked at many of the tricks you must have, because you would not have a doctor in some of these countries.

I would find—this also happens in European countries—that there was always an expert, ancien or wise man at local community level. While we look at the bigger picture of great hospitals and expenditure, little community activities seem to work extremely well in some other countries. In many of them, there is now a tendency to devolve and plurality is starting to arrive, as the noble Lord, Lord Warner, said. We could never reproduce the noble Lord, Lord Warner, so plurality is perhaps the wrong word; perhaps I should say the repetitiveness of certain services. As the noble Lord, Lord Morris, said, the nearer to a person’s home, the better.

The age profile interests me. I remind my noble friend Lady Byford that the House of Lords has more people over the age of 80 than any other body in the world, roughly 15 per cent. When I have had foreign consultants here, and we have wandered around the corridors, they have said, “We don’t need to go any further to have a perfect sample of almost every form of disability or activity in the world”. Noble Lords also have the advantage of being kept active so they will live to an older age.

At local community level in many countries, I now find that the ambulance system comprises of three groups of people: people’s children who, after their driving test, learn to become intermediate ambulance drivers; the ordinary paramedics who will turn up at any moment; and the fire brigade or community services, which will arrive within eight minutes. It is much better to ring them up because if there is a woman patient, they will send a woman doctor, a male paramedic and two others within a short time. At the other end, removing people from hospital at an early date and providing local community services that will take them back as out-patients, deal with their drips, care for them, talk to them and not leave them alone is much more economic and efficient, particularly as we have modern technology.

Noble Lords will remember that one of the greatest scanners in the world was the British EMI scanner. If we look at diagnostics now, there is new equipment. Scanners can produce 128 slices instead of the normal 28 or 56 and can do a dual scan in half an hour. If referral could be made quicker, the throughput could be enormous. Noble Lords may be aware that there is a scanning operation just down the road that requires only six to eight people a day to cover itself.

I feel that we should get away in thought from large hospitals and large bodies and stop arguing about whether PCTs have enough money. We should go back and start from the community and work upwards, rather than from the top downwards.

My Lords, I, too, congratulate the noble Baroness, Lady Gardner of Parkes. I hope she will forgive me for saying so, but I have come to think of her as the nearest thing the House of Lords has to Shane Warne because she casually strolls up to debates and bowls the Government some issues and who knows what will happen as a result? Today is a perfect example of that. We have had a fascinating debate with a range of extraordinary contributions. The noble Baroness, Lady Fookes, took us off in an interesting direction, and the noble Lord, Lord James of Blackheath, gave a marvellous contribution because he is right that, until such time as we get to the bottom of the exact position of NHS funding, we are all shooting in the dark. My understanding is that last year the Government were forecasting an NHS deficit of about £500 million, so the figure of £94 million is likely to be very inaccurate.

We also know from several surveys that, at the moment, social care is underfunded by about £1.8 billion. That is an important place to start. In her opening speech, the noble Baroness, Lady Gardner of Parkes, spoke about the dividing line between health and social care. I want to talk about the interface and the overlap. It is important to do so now when we are in the run-up to CSR07 and when the Government, following a period of consultation, are about to announce the policy they intend to adopt on NHS continuing care criteria.

A lot of the debate centred on the relocation of health services. There has been a lot of predictable outcry when services such as A&E wards or maternity services are closed. What rarely make the headlines are the consequences of those policies on non-emergency and non-elective procedures and, in particular, the consequences for social care.

The British Geriatric Society, in its response to the consultation on NHS continuing healthcare and NHS funded nursing care in England, published in November 2006, noted that, in 2005, there was a loss of about 1,400 rehabilitation beds. More were lost in 2006. The effect of that was that people who had chronic disabilities and had undergone serious health problems such as strokes were being sent back into the community with far less rehabilitation.

The society noticed also that there had been an increase in admissions to hospitals because of the out-of-hours GP contract. What is increasingly happening is that an out-of-hours service gets a telephone call from an elderly person whom it does not know. To cover its back, it will send them into an acute admissions hospital, to doctors who also do not know them. Noble Lords should contrast that with the service outlined by the noble Lord, Lord Taylor of Holbeach, which runs effectively and well, and is reliant on people knowing in depth the patients whom they serve. There were many unforeseen consequences of the way in which the Government negotiated the GP contract. That was one of them. As the noble Baroness, Lady Byford, said, it has been an exercise in cost-shifting rather than in pooled budgets and joint working.

An assumption was made in many of today’s speeches that the transfer of care from an acute to a community setting would somehow be a straight replacement and cheaper. That is not always the case. As the NHS Confederation pointed out when it was talking about the future of general hospitals, although it is possible to move some functions such as rehabilitation which are now carried in acute hospitals—even intensive rehabilitation following an operation—there is never a point at which a functioning general hospital does not need that facility within its walls. In some cases, we are talking about duplication.

We are in the run-up to elections in Scotland. Therefore, the media south of the Border are beginning to pay attention to what is happening in Scotland. They are beginning to talk about the Scottish Executive’s policy of free personal care. Much of that reporting has been misleading and simplistic. It is important to look at it because it has important lessons for those of us in England.

Research from Stirling University, which was commissioned by the Joseph Rowntree Foundation and published in 2006, looked at the financial models of care in Scotland and the UK, and it came up with some interesting findings. It found that the introduction of the free personal care policy did not reduce the level of informal care, as had been predicted. Rather, it enabled carers to cope and to provide other forms of care, and, in some cases, to keep on working. It became an additional service and not a substitute. They found that the difference between Scotland and the rest of the UK in the public costs of personal and nursing care are very much smaller than is popularly assumed. In Scotland, people who are in residential care do not receive attendance allowance, for example; but they do in the rest of the United Kingdom.

It has been said frequently that the cost of the introduction of that policy has been a great deal higher than was expected. Yes, it was £143 million in its first year instead of £125 million. That is still only 0.2 per cent of the gross domestic product. Much of those costs would have arisen in any case. Care standards, for example, were introduced in Scotland and they had a cost attached to them.

Depending on the rate of demographic change and whether the costs of care rise in proportion to inflation, it is true that the cost of that policy could triple to 2 per cent of GDP by 2053. However, in the intervening period, there is an opportunity for Government to take action that would offset it; for example, by prolonging the periods of healthy life in older people and, crucially, by extending care at home.

The introduction of free personal care policy has had a beneficial impact on two groups of people in particular—older people with modest means and savings, often women, and people who have Alzheimer’s disease. If noble Lords think about many of the cases in the past two years where appeals have been won over continuing NHS care against decisions to refuse free nursing care in England, it is those people who are being disadvantaged by the unclear policy that this Government have deliberately pursued for the past seven years.

It is difficult to extrapolate directly from the experience from Scotland to the rest of UK. That is not because there are huge demographic differences. In practice, there are greater demographic differences within the four nations of the UK than there are between them. It is difficult to equate the fact that our system of social care funding is much more complex, and it is difficult to draw a parallel when much of the costs of social care are covered, for example, by the housing and benefits system—the benefits system is slightly different in Scotland.

Perhaps the most important finding of the Scottish study is that the implementation of that policy of free personal care has enabled carers to cope and it has caused a transition of care to move away from institutions and towards homes. When noble Lords stop to think that the annual cost of caring for an older person in their own home in Scotland is £3,000, they should contrast that with the annual cost of residential care—there is a dramatic difference.

Two weeks ago, CSCI presented its report on the future of social care. It called for a full and open debate about the settlement between the state and individuals about future care costs. We have known for many years, and all parties have accepted for many years, that since the major debates on the Royal Commission on the future of long-term care, the state will not pick up the full cost of social care. It is unlikely that it ever has done that. What is not clear, and is certainly not clear to individuals, is the likelihood of their social care provision being met by the state when they are older. Many people have wholly unrealistic views of what that is.

My suggestion is one that we have been making to the Government from these Benches for a long time—since the publication of the Royal Commission report: just as is the case with pensions, there is a need to come to a settlement in which there is clarity, simplicity and an understanding of which aspects of social care will be paid for by the state and which will have to be paid for by individuals. Until we do that, we will have a continuing system of fragmentation for those who are trying to deliver social care and utter confusion for those who receive it.

My Lords, I begin by thanking my noble friend Lady Gardner for introducing her Motion so clearly and so well and for having chosen a topic which we surely need to discuss and revisit regularly on occasions such as these. Like her, I see this short debate as an opportunity.

It is now just about a year since the Government published their White Paper, Our Health, Our Care, Our Say. That document was in many ways a landmark statement of policy. I was, and remain, enthused by a great deal of its content. Its ambitions were noble, its aims were absolutely to the point and, on the whole, it was realistic in so far as it set out a timetable for change that appeared reasonable. Therefore, as is not infrequent in health matters, we find ourselves sharing the Government’s aspirations about the increasing emphasis that we should be placing on delivering health and care services in community settings. We are very much with them on the idea of more and better joint working between health and social care. We are also enthusiastic about encouraging patients to be more independent, particularly those with long-term chronic conditions. We warmly back the idea of better support for carers.

That is the good news. The areas in which we find our doubts and fears coming to the surface are to do not with policy but with delivery. Many of the contributions today have focused on one or other aspect of that, and I believe that this kind of scrutiny is timely. I want to concentrate on three areas where there are real barriers to delivering the Government’s community health agenda. They are funding pressures, commissioning and training.

Funding pressures are a hardy perennial of these debates, but absolutely crucial in the context of my noble friend’s Motion. A lot of the problem stems from the acute sector. The combination of deficits in acute trusts, combined with government targets for elective treatment, has had a severe effect on the money available for rolling out the delivery of care in the community. A year on from the Secretary of State’s assurances that no community hospital should close purely because of short-term budgetary pressures, 105 are still under threat of closure. The Government say that closure of beds does not always matter. Certainly, one can make a theoretical case for the closure of some beds, or whole hospitals, if joined-up community services are there to take their place, but we are still a long way off being able to make that claim. PCTs have seen their budgets top-sliced this year to feed the voracious appetite of the acute sector. That has seriously affected their ability to invest in community services.

For example, there is a government target to create 3,000 community matrons by March of this year—nurses whose job it will be to keep people with chronic conditions at home and out of hospital. The latest Written Answer on this says that only 267 community matrons are so far in post. That figure has probably gone up, and the RCN believes that it is higher, but it is quite clear that the target will not be met by a wide margin. What about health visitors? The number of health visitors, if one looks at full-time equivalents, has gone down since 1997, and even since 2001. The number of midwives working in the NHS declined last year, even though the number of births went up. Midwife-led maternity units and birth centres are closing or under threat.

In general practice, there are further concerns. Many areas of the country are under-doctored, but we find that schemes encouraging doctors who have left the NHS to come back have been cut. There are also cuts in flexible career initiatives: 60 per cent of GPs recently surveyed said that their premises are unsuitable for present needs, let alone any expansion of activity stemming from the White Paper. Nearly half of all practices have complained that they cannot now provide enhanced healthcare services, because the budget for these has been withdrawn by the PCT. Yes, one can point to progress in some localities, and I am sure that the Minister will do so. The Making it Happen paper published in October refers to some successes, but they are patchy and as yet small in scale. All too often, the necessary momentum is simply not yet there.

At local government level, the picture is no less difficult. According to the LGA, seven out of 10 local authorities have found themselves hit by the withdrawal of NHS funding from jointly funded projects, or by a sharp increase in the referral of patients who would normally be cared for by the NHS. Some have experienced both, and the funding shortages are such that many authorities have reported increased waiting times for assessments and for social care services, while many are withdrawing services altogether. The structures for joint working are, in many cases, being put in place; but the means to achieve a step change in delivery are absent.

In many parts of the country, the squeeze on PCTs is not helped by the formula underlying the funding—the so-called resource allocation formula. I have serious worries about the effect of the current formula on areas of the country where there is a high burden of disease but relatively low premature mortality. The Government’s current formula weights the funding in a way that does not give sufficient emphasis to morbidity, as reflected largely in the age profile of the population. The result is that capitation payments in many areas are insufficient to cover existing demand for healthcare, let alone any heavier demand. I am aware that the Government are currently awaiting the weighted capitation formula. It would be helpful to know when the review is likely to be complete. My honourable friend Mr Lansley wrote to the Secretary of State about this more than two months ago but is yet to receive a reply.

My second concern relates to commissioning. Commissioning by PCTs is still weak. Part of the weakness lies in lack of skills, but part also lies in poor financial management. Of the 303 PCTs rated by the Healthcare Commission last year, none was rated excellent for use of resources. Only 24 were rated good and 124 were rated weak, which means that immediate action is required to remedy failings. In total, nine out of 10 PCTs were rated weak or barely adequate for their financial management. That is a hopeless basis on which to expect the ambitions of the White Paper to materialise successfully.

Meanwhile, payment by results is with us. One of the recognised features of payment by results is that it incentivises activity. Unless there is effective demand management on the commissioning side, the supply side, in the shape of acute trusts, will tend to suck in money from commissioners. At the same time, the tariff set for in-patient care is very broad brush. Rolled up in it is an element designed to cover the cost of convalescence. The tariff therefore provides no incentive to an acute trust to discharge a patient into step-down care in the community. Until the tariff is unbundled to separate the cost of intermediate care, the business of getting patients out of acute settings will continue to be hampered. The Government have insisted that such unbundling, if it is to happen, must take place locally, but they know full well that that is a tall order when both acute trusts and PCTs are already under severe pressure and in many cases overspending.

My third concern is training. In the domiciliary and care home workforce, a large majority lacks training of any kind. Only 10 per cent of care home staff have any training in looking after people with dementia. On the nursing front, we have heard from the RCN this week that training for new district nurses and health visitors is being cut back drastically in many parts of the country. That is concern enough; but there is a wider issue here.

Despite the changing role of nurses, and increased specialisation into fields such as long-term conditions and public health, there is still nothing that one could describe as an established career pathway for nurses; nor are educational funding streams linked to the future shape of the nursing workforce that we all want in place. That lack of a career pathway for nurses and the absence of appropriate funding streams was one of the warnings made by Professor Dame Jill Macleod Clark at the major nursing conference that took place in London this week. I hope that the Government will heed it.

My overarching worry in the delivery of Our Health, Our Care, Our Say is that although the Government may have willed the ends, they have not sufficiently willed the means. The system is creaking badly; and it is very difficult to see how the five-year time horizon which the Government set themselves in the White Paper will be deliverable. At any one time, there are up to 1.5 million vulnerable people, notably the elderly, most of them at home, dependent on social workers and support staff for help. There are 17.5 million people with chronic diseases who are reliant on the NHS. For the sake of those people, I hope that if we revisit the issues in a year’s time, we shall be able to point to a somewhat rosier picture than the one currently before us.

My Lords, I join other noble Lords in congratulating the noble Baroness, Lady Gardner of Parkes, on securing this debate. Her knowledge, interest and support for the National Health Service are well known and I was delighted by the tenor of her speech. She chose a wide topic, which noble Lords have made wider still. In fact, we seem to have had a sort of Queen’s Speech debate about the whole health and social care system, and why not?

The noble Baroness talked about mortality and demographics. Since my noble friend gave up being a health Minister, he looks 10 years younger; I certainly feel 10 years older. In a wholly objective way, he analysed the stewardship of the past Government and the achievements of this one. I can but endorse his assessment.

In some excellent speeches today, we have heard concerns that noble Lords legitimately have about the challenges facing the health and social care system. I would not seek in any way to underestimate those challenges, though I will respond to them. We just need to bear in mind the huge advances that have been made over the last few years, such as in the number of staff now working in the health service—about 325,000 more people than in 1997. The resource is going in, including capital investment, and above all the staff are doing fantastic work to develop services, reduce waiting times and give the people of this country the health service that they undoubtedly require and ought to have.

On this question of targets and priorities, I remember a search for how many priorities the health service had in about 1993, when I was working for the National Association of Health Authorities. We discovered about 57 and thought that we had better stop there. Whichever party is in government, there are lots of things that they will wish to achieve in a publicly financed national healthcare system. We, too, went down the target route. I believe that that was essential at the time, as we put resources into the NHS plan. Many of those targets have now achieved their purpose, and we are moving on to system reform, in which there are a number of components.

First, there is a lot more emphasis on the individual personal care that patients should receive from the NHS, much more accessible services and more choice. Of course there have to be some central targets; that is the deal with the taxpayer. It is absolutely right on such an issue as waiting times that the Government set a target for the NHS as a whole. The system of regulation and standards at the national level allows you to give much more freedom to individual organisations at the local level, with the financial incentive that payment by results gives to reward the best performers. We move from a situation where there have been a lot of centrally directed targets to a new system where there is a great deal of emphasis on the personal service to the individual patient, but with the safeguards of national regulation and safety standards. I am sure that that is the appropriate way to go.

We have all had a go at restructuring the health service and the noble Baroness invites us to have yet another go in health and social care. We have learnt that, whatever the structures, the key thing is whether people work together. Are there the right incentives? Can we remove the barriers to organisations working together? We have decided that it is better to try to get the incentives right to encourage people to do the right thing and to work together.

Nowhere is this more necessary than in commissioning. The changes that we have made, such as the reduction in the number of strategic health authorities and primary care trusts, 70 per cent of which will now be coterminous with the relevant local authority, have been a sensible approach alongside improvement in the capacity of the NHS to commission effectively. The noble Earl, Lord Howe, talked about commissioning capacity. I accept that the commissioning skills of many PCTs needed to be enhanced, but we believe that reducing the number of PCTs and strengthening commissioning capacity is the way to achieve an effective inter-relationship both between PCTs and NHS organisations and between PCTs and local authorities in the services that they provide. That will lead to a much greater integration of services. The department and the chief executive of the NHS have signalled that leadership and managerial capacity and its enhancement are among his key priorities, and I very much intend to support him in that.

The noble Baronesses, Lady Masham and Lady Shephard, talked about the role of GPs and the out-of-hours experience. Let me say just one thing about the GP contract, to which quite a lot of attention has been given in recent months. The essential part of that contract is the direct relationship between the performance of GPs, in the quality and range of services that they give to their patients, and the financial rewards that they receive. That relationship is unique in modern healthcare systems throughout the world. The question of money has been about GPs exceeding the expectation of the degree to which they would provide the services according to the quality contract. We can build on that, but the structure is there to incentivise GPs to do the right thing by their patients. The result has been more services in primary care, more and better access, and more services such as minor surgery.

On the question of out-of-hours services, my experience in Birmingham is that the role of the PCT in securing the quality of those services has led to very much enhanced service at the weekends and in the evenings. However, I take note of comments that have been made. We expect PCTs to act as guardians of safety and quality, which noble Lords have discussed.

My Lords, I very much appreciate the fact that the Minister is trying to address the concerns expressed in the debate. Does he accept that there is a fundamental difference between the kind of geographical area that must be served in Birmingham and the kind of geographical area that must be served in, for example, North Yorkshire or Norfolk, and that in the latter cases sparsity of cover has a real effect?

My Lords, I am always tempted to talk about Birmingham, because that is what I know best. I recognise that there are very different characteristics and that some of the organisational issues and challenges that would be faced in Norfolk and North Yorkshire are very different from those to be faced in downtown Birmingham. However, the key issue is still the same. It is the responsibility of the primary care trust to ensure that people in those areas receive a quality service. That is what we will monitor them against.

We have heard a lot about deficits. First, I apologise to the noble Lords, Lord James and Lord Selsdon, for the fact that their Written Questions have not been answered. I have double-checked, and I am assured that they await my earnest attention. I will ensure that the noble Lords receive those Answers as quickly as possible. I will certainly ensure that the DoH improves its performance.

We have had a problem this year with deficits, and we decided that it would be much better to sort them out once and for all and to put the NHS back on a sound footing than to allow the deficits to continue and to fester. That has meant that some very difficult decisions have had to be taken this year, but it is our firm view that getting rid of the deficits of the NHS as a whole at the end of the year is the vital foundation for ensuring that future resource investments are made on the basis of long-term planning, as opposed to people having to take some very short-term and difficult decisions. The noble Lord, Lord James, asked some interesting questions about the definition of a deficit. I will not rise to the challenge of giving him a very technical answer now, although I promise to give him the answer in writing, which I will copy to other noble Lords. Essentially, for the National Health Service, clearing the deficit means exactly what it says.

The noble Baroness, Lady Masham, rightly mentioned MRSA. These are very tough challenges, but we have ensured that the NHS is taking the issue seriously. We have set a very challenging target and have local targets for C. difficile. The indications are that MRSA rates are coming down. We need to redouble our efforts, but I do not think that anyone in the health service is under any misapprehension that this very serious matter has to be tackled. My noble friend Lord Morris is right about the essential principles of the NHS and the tackling of health inequalities.

I endorse the views of the noble Baroness, Lady Byford, on the contribution of the WRVS. I also agree with her about the challenges of increased longevity; it is clearly a major challenge for our health and social care systems. Direct payments are available and, we believe, have been greatly welcomed. Thirteen local authorities are piloting individual budgets in order to get evidence to enable decisions to be taken on whether this should be rolled out nationally. Clearly, again, we see great potential there.

My Lords, my briefing from that paper indicated that that would require primary legislation. Will the Minister clarify that?

My Lords, I am not aware that it needs primary legislation, but I will double-check to make sure that I have got that right.

The noble Lord, Lord Selsdon, made some interesting comments, particularly on the potential of new equipment. There is no question but that there will be huge gains in productivity and speed of access to treatment the more quickly we can adopt proven new technology. We are committed to encouraging the NHS to embrace innovation as fast as it can. I also agree with him on the need to look at the provision of services in a bottom-up way. My understanding is that the resource allocation review will be completed by autumn 2007, and I am sure that there will be a great deal of interest in that.

The noble Baroness, Lady Gardner, questioned how well partnerships are working. She suggested that it might be all right at director level but that, for people working in the field, it is not so hot. I do not share that view. None of these partnerships works without the staff of both organisations being committed. I accept that sometimes barriers come in the way of that, but the progress that has been made on delayed discharges and in the hundreds of Health Act partnerships that have been developed has been the result of a lot of people doing a lot of hard work in different parts of the country, which we need to support.

The noble Baronesses, Lady Gardner of Parkes, Lady Byford and Lady Shephard, referred to resources. I will not repeat what I said in last week’s debate on social care. There has been growth in the social care sector. Of course, I know people are arguing that it is not sufficient. The LGA report, Without a Care?, has proved to be of great interest to us all. It says that there is enough money in the system, but that it is in the wrong place. For local delivery mechanisms, the Government need to shift resources from acute NHS care to social care. I know that the LGA has also expressed serious concerns about whether central government funding is keeping pace with demographic change. These are issues that fall to be considered in our discussions in the next spending round. But I say to the noble Baroness, Lady Barker, that account was taken in reaching the 2004 spending settlement of pressures arising from rises in demand, pay and prices. There may be a debate about how successful that has been, but part of the spending review settlement process is to pick up and identify those issues.

There is of course continuing debate about the question of personal care as opposed to nursing care. Noble Lords will recall with fondness our great debates on these matters. Coming back to the LGA and the comments made by the noble Lord, Lord Bruce-Lockhart, I would say to the noble Baroness, Lady Barker, that we are working closely with the LGA and the ADSS to identify long-term funding requirements for social care that will inform the spending review. We warmly welcome those kinds of debates. We understand the issue of demographic pressures. The evidence presented by Sir Derek Wanless is a matter of great interest to us all and we will feed it into the process. I also accept the comment made by the noble Baroness, Lady Gardner of Parkes, about promoting financial flexibilities. We will continue to do that and to ensure that advantage is taken of them.

The noble Baroness, Lady Fookes, made a fascinating speech about the links between the long-term unemployed and their health and life outcomes. She will know that I have just come from the Department for Work and Pensions, so what she said was music to my ears. The work being done by Tomorrow’s People sounds wonderful. She says that advice coming from a neutral source for people who have perhaps been on incapacity benefit for a long time may be better received. I understand what she is saying, but the Pathways to Work pilots that my previous department undertook also showed that, when you work positively with people and give them the confidence and support to consider work again, even if they thought that they would never get back to work, that can have a remarkable and hugely beneficial impact when they do get back into work. I agree with her that having employment advisers based in GP surgeries is an excellent idea. It means that when a GP is asked to sign a sick note they can offer a constructive alternative. That would be very positive. I shall certainly ensure that her comments are passed on to my noble friend Lord McKenzie of Luton, who now has responsibility for that.

Noble Lords made a lot of comments about the value of community hospitals. The experience of the noble Lord, Lord Taylor, was interesting and very encouraging. Let me repeat the Government’s policy on community hospitals. We have made it absolutely clear that we want more services to be provided in settings that are convenient for patients, such as community hospitals, primary healthcare centres and similar facilities. We have also made it clear that closures should be proposed at local level not in response to short-term budgetary pressures but only where a particular facility is not considered clinically viable or is not being used effectively.

In this great world of devolved decision-making, which both parties are now signed up to, it is not for Ministers to intervene when there are local discussions. It would be wrong for us to do so. Our job is to signal the importance of what many community hospitals can provide. That is why the £750 million capital programme was brought into being; it will encourage the provision of better facilities. On 22 December, my noble friend Lord Warner announced the first schemes to receive funding from the programme. So while I accept that at the moment some difficult decisions have to be made, noble Lords can be assured that we believe that community hospitals are a very important part of the development of community services.

My Lords, before the noble Lord sits down, I thank him for the eleven and a half minutes that it took to get the Answer to my Parliamentary Question, which I am holding in my hand.

My Lords, we have just two minutes left. I thank the noble Lord for how well he has answered the debate, but I must comment on the usual party political from the noble Lord, Lord Warner. I want to make it clear that I have no official status in anything that I have said today. He thought that I was quoting party policy. If the party takes it up, I shall be delighted, but I do not have any official role.

I was pleased to hear the noble Baroness, Lady Masham, talk about specialist nurses, because I could not speak more highly of any group. I loved the contribution made by my noble friend Lord James of Blackheath. It is typical that no one asks questions about millions of pounds. On any committee, if you are debating something that costs £50, you will spend half an hour on it, but the millions go through on the nod. So it is good to have someone like my noble friend Lord James closely following up those matters.

All the contributions to the debate were marvellous. They were so varied that we have had a thorough debate. My noble friend Lord Taylor set out a wonderful history for us, one that sets an example for others. My noble friend Lord Selsdon is always a joy to listen to, as he is one of the best speakers in the House. The noble Baroness, Lady Barker, made a superb contribution, which does not surprise me, because her experience is so great. We could have spent much longer on this debate and I think that everyone would have liked more time to speak. It has been very worth while. I thank all who participated and I beg leave to withdraw the Motion for Papers.

Motion for Papers, by leave, withdrawn.