HC Deb 01 December 1976 vol 921 cc1122-34

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Coleman.]

1.11 a.m.

Mr. Kenneth Baker (St. Marylebone)

I am pleased to raise on the Adjournment the subject of the allocation of money to London hospitals and the threat that this will carry to medical services in central London and even to the teaching hospitals themselves.

The House will know that all health authorities are being asked to trim their expenditure. I am not complaining about that, and London must take its fair share of the cuts. But I believe that London is being asked to take too high a proportion of the cuts as a result of the working paper called "Sharing resources for health in England", the Report of the Resource Allocation Working Party, which was published earlier this year. The working party says that National Health Service resources should be shared round the country, and it means, in effect, that the four regional health authorities which meet together in the centre of London will all have substantially less, and this will affect the services in central London.

The case of this document is that the London area is over-provided for, and I can see that there is some strength in this argument. But it is a totally exaggerated strength. I accept that the population of London is declining and, therefore, that the services available to London in the health area and even more significantly in the educational area, as any London Member knows, will have to be reduced over the years. But I object to the damaging effect that will result in the London hospitals if the proposals in the document are implemented on the scale and in the time scale recommended.

Many parts of the document are ill thought out, and I suspect the philosophy behind it. There is a feeling running through the document that London is just one huge champagne belt which is rich and prosperous, when any London Member knows that this is not the case. There are areas of considerable social deprivation in London. One has only to drive through North Kensington, Paddington, my former constituency of Acton, Shepherds Bush, or Hammersmith, or to cross any of the bridges outside this House and go through the boroughs of Bermondsey, Southwark, Brixton, Lambeth and Wandsworth to realise that these are areas of social deprivation judged by any standard. Many of these areas have a high level of unemployment. The general level of unemployment in the London area is just over 4.3 per cent. but unemployment in Poplar, Stepney and Deptford is in the region of 12 per cent.

These are the classic inner city areas where there is poor housing, poor job opportunities and declining services. It is these areas which the Secretary of State for the Environment is saying ought to have more resources devoted to them. Yet the Secretary of State for Social Services is saying exactly the reverse.

What would be the consequences of the recommendations of this working party for London? In a letter to The Times today Sir Francis Avery Jones, the chairman of the medical committee of St. Mark's Hospital, said that if the recommendations were implemented they would have the effect of reducing purchasing power for the London regions by an amount just over £100 million a year. My constituency lies in the region of the area health authority for Kensington, Chelsea and Westminster—the North-West Thames area. If anyone was asked to name the three most prosperous parts of London I dare say that he would name those three areas. That would be totally erroneous.

A report prepared for the Department of the Environment was underaken with a view to identifying the worst areas of urban deprivation in Great Britain and promoting a partial test of the appropriateness of area-based policies of positive discrimination. An analysis was made of areas of urban deprivation. It was found that of all the local authorities in the country Kensington and Chelsea ranked sixth from the top of those suffering the worst urban deprivation. Westminster was fourteenth in terms of total population affected. I hope that I have shown that London is not a glittering jewel which can be plundered and the resources spread over the rest of the country.

If those recommendations of RAWP are implemented, my area health authority fears that there will be the loss of one teaching hospital. In the area health authority of which my constituency forms a part there are six centres of excellence as they are called. There are four teaching hospitals, Charing Cross, Middlesex, St. Mary's and Westminster. There are also the post-graduate school at Hammersmith and the clinical researeh centre at Northwick Park. Institutions like these are unique. Not only are they the envy of the rest of the country; they are the envy of the world.

I have mentioned only six of the teaching hospitals in the area health authority with which I am concerned but there are 22 such centres of excellence in central London. I ask the Minister to give an absolutely categoric assurance that not one of these will be closed down as a result of the RAWP report. I want a complete assurance that not one will be lost.

Why do I ask this? I have already referred to the letter written by Sir Francis Avery Jones. He goes on in that letter to say that if these proposals are introduced: We believe that a reduction of this order must mean closing major hospitals as well as small ones. If so, within a few years London's position as a leading international medical centre and as an important invisible export would be jeopardised. No longer would London be able to maintain its key rôle in higher specialist training for the whole country. On Monday, Professor Kinmouth, also writing to The Times from the Department of Surgery at St. Thomas's Hospital Medical School, just across the river, argued that this dispersal of medical excellence was wrong for medical reasons. He spoke of where this had happened in the past and said: We have only to look at medicine in the world as a whole to see where it leads. To the cast we see several countries which have adopted this policy of devolution and dispersal of resources. The chief of them has produced no notable advance in surgery since the war. To the west we see America where excellence is encouraged. This year workers in American centres won all of the Nobel prizes for medicine. I am convinced that a loss of any of these centres or a significant run-down in any of them would be highly damaging to the medical services, not only of London but of the whole country.

If the Minister says "We shall keep all these centres of excellence", the implications for the rest of the medical services of the area health authority are significant. Other hospitals might have to be closed, other services reduced. In my own area there is a serious danger that St. Charles Hospital in Ladbroke Grove will be closed. The House probably heard last week about the weekend closure of St. Bartholomew's. At the Hackney Hospital, which is in a deprived area—I suppose that is the buckle of the champagne belt—two general wards and one children's ward are to be closed. There is St. James's Hospital at Balham and St. Nicholas's Hospital at Plumstead; the sword hangs over them all.

The Minister will know that in central London the Elizabeth Garrett Anderson Hospital is about to be closed as well as St. George's at Hyde Park Corner. I believe that this working party did not take two special factors into account. The first is London's floating population. At the Westminster Hospital, just across the road, two out of every three patients do not live within the district of the area health authority. I dare say that half their patients do not live in London. Yet London has to pay the cost of the hospitals from which the rest of the country benefits. The district of area health authority of which my constituency forms a part has a population of 420,000 people, but the authority estimates that it has to provide medical services for a million people.

I have already mentioned the second factor, which is that this document does not take social deprivation into account. There is also the technical argument, important in medical circles, that the report depends too much upon mortality rates rather than morbidity rates.

I hope that I shall get an undertaking from the Minister this evening, because there is a great deal of anxiety about what the report will mean to London. If the Minister wants savings, he should not look for them in the teaching hospitals and centres of excellence, or in the small local hospitals which serve our communities. Most of my constituents, and probably those of any other hon. Member, prefer to go into small rather than large hospitals. Let the Minister look for savings in the enormous scale of administration in the Health Service.

The Minister of State, Department of Health and Sociel Security (Mr. Roland Moyle)

It was the hon. Member's own Government who imposed this administration upon the Health Service.

Mr. Baker

That is the point that the Minister always makes, but he is now responsible for the administration of the Health Service. It is a national scandal that over the last 10 years the number of administrators has increased by 31,000 and the number of doctors by 11,000. That includes the years before the reform came into effect. I quite accept that the administration is far too top heavy and should be looked at again. There are many features that we could look at in the structure of area health authorities and regional health authorities. We should, perhaps, abolish the regional health authorities. The Government must think again about this proposal. They should not introduce a panic measure that will do irreparable damage to services and hospitals that have taken centures to build. We are still the world capital of medicine and it is absolutely absurd to destroy something which the rest of the world envies. I hope, therefore, that, this matter having been brought to the attention of the House, the Minister will give a categorical assurance that this report will be put on the shelf and the dust allowed to accumulate upon it.

Mr. Michael Stewart (Fulham)

rose—

Mr. Deputy Speaker (Sir Myer Galpern)

Order. I did not know that the right hon. Member for Fulham (Mr. Stewart) wished to speak. Has he the agreement of the hon. Member who initiated the debate? That is the custom.

Mr. Stewart

I do not have the agreement of the hon. Member for St. Marylebone (Mr. Baker).

Mr. Deputy Speaker

Does the hon. Member for St. Marylebone (Mr. Baker) object to the right hon. Gentleman's taking part in the debate?

Mr. Baker

As I told you, Mr. Deputy Speaker, two of my hon. Friends asked to take part in the debate. I have no objection to the right hon. Member for Fulham (Mr. Stewart) also taking part.

1.25 a.m.

Sir George Young (Ealing, Acton)

I am grateful to my hon. Friend the Member for St. Marylebone (Mr. Baker) for the opportunity to support the case which he made so eloquently. It is difficult to oppose the general case that one should try to equalise the resources available to the National Health Service throughout the country, but there are reasons for treating the working party's report with suspicion.

First, it would be almost impossible to implement the recommendations in London. I have a letter from my area health authority which says that the report would almost inevitably mean the closure of one of the major hospitals in the area. Yet yesterday, we were given an assurance by the Minister that no major hospitals would be closed. The authority in my area wants to know how it is to achieve economies totalling £30 million without closing one of the major hospitals. In practice, it will be impossible to implement the recommendations of the report in London.

What the Minister is trying to do goes clean against the work which is taking place in the Department of the Environment where, at long last, it has been recognised that the plight of inner cities needs urgent attention and that resources must be switched to them. The Secretary of State for the Environment is trying to arrest the flow of population and resources from the inner cities, but his belated efforts are being negated by what the DHSS is trying to do.

If we are to equalise resources within the NHS, it can be done only at a time of economic growth. Trying to do it during a period of nil growth or recession would be suicidal. I urge the Minister to look again at the report and to announce that it will be implemented only in the context of economic growth, thereby avoiding the traumatic decisions which will otherwise have to be taken in London, particularly West London.

1.27 a.m.

Mr. Peter Bottomley (Woolwich, West)

I thank my hon. Friend the Member for St. Marylebone (Mr. Baker) for the opportunity to take part in this debate.

I remind the Minister that he recently received a petition signed by 16,000 of my constituents calling for the retention of the Eltham and Mottingham Hospital. Will the Minister remind the local area health authority that if it wants to save money, it cannot afford a new health centre in the grounds of a hospital which it means to close because of lack of money?

One-third of the people in my constituency do not have cars and if this proposal is implemented they will have to take three buses to get to the nearest general hospital.

1.28 a.m.

Mr. Michael Stewart (Fulham)

The Secretary of State assured us yesterday that no teaching hospitals in London will be closed. Indeed, he put it even wider than that. It is difficult to see how that undertaking can be met if the principles of the report are put into operation. I trust that what my right hon. Friend said yesterday means that the Government will not go ahead—or will go ahead only slowly—with the ideas in the report.

May I make a special plea for the Charing Cross Hospital which is in my constituency? It is unique among recently-built large hospitals in that it was completed within the time originally scheduled for construction and that it cost less than the original estimate.

The hospital is doing unbelievably good work as a teaching hospital and for the people in the neighbourhood. I beg the Minister to make clear to our right hon. Friend the Secretary of State how deeply felt are the anxieties about this and other hospitals as a result of recent reports. We look to him to allay these anxieties and to give us reassurance.

1.29 a.m.

The Minister of State, Department of Health and Social Security (Mr. Roland Moyle)

I am glad that we have had this debate. The hon. Member for St. Marylebone (Mr. Baker) has raised a matter of equity and in doing so has revealed a number of the current misconceptions about the working party's report. It gives me the chance to comment on them and refute them.

The subject which the hon. Gentleman has raised is an alleged unfairness in the distribution of money within the National Health Service. What is being opposed is my right hon. Friend's policy of achieving greater fairness in that distribution, a policy which has been accepted by Governments of both colours for many years, but to which we are now giving new emphasis.

No one would dispute that historically there have been great inequalities in the facilities, the levels of finance and hence the levels of service available in different parts of the country. The four Thames regions have been better endowed than the rest, particularly in hospital provision. Excluding the cost effects of the teaching hospitals the scales used by the Resource Allocation Working Party show current expenditure per capita in London as North-East Thames £85; North-West Thames £84; South-East Thames £78; and South-West Thames £76. This compares with a national average of £72, and expenditure per capita of £64 in the Trent and North-Western Regions.

I do not need to be reminded that costs and wage levels are different in London, nor that the London medical schools train one third of the country's doctors and that this imposes extra costs. But I should be astonished if anyone were to argue that they alone justified present disparities, although it is admitted that there are areas of acute inner city social deprivation in London, and I shall mention these later.

I hope, however, that no one will suggest that we shall solve the problem by pumping in more money to raise the standards of the lower regions to the best. That will mean an extra £600 million. If hon. Members opposite are proposing that public expenditure should be cut by £4,000 million to £5,000 million, that option is out.

A year ago the Government established the Resource Allocation Working Party, which has issued two reports. Its first and interim report was used as a basis for allocation of money in 1976–7. Its final report, which came out a couple of months ago, is still out for consultation. The working party's task was to recommend the criteria upon which long-term allocations of money should be based. Application of those criteria naturally shows what imbalances there are, but it does not show how quickly they should be corrected. That is a matter for political decision. As my right hon. Friend said on 25th November: The tighter funds become, the more difficult it is to make a rapid shift."—[Official Report, 25th Nov., 1976; Vol. 921, c 319.] My right hon. Friend has not yet decided whether to accept the working party's report. If he does, that will not commit him to a particular timetable for implementation. In any case the pace of progress will be a matter for discussion by the Government and by health authorities each year. For planning purposes it is necessary to make assumptions for several years ahead, but that does not imply firm commitments. The working party itself recognised that it had not dealt fully with cost differences and recommended various subjective adjustments pending further investigation.

We have introduced into the NHS a new planning system. This is the first year of its operation. All health authorities are reviewing their services and producing strategic plans for their services over the next decade or so and operational plans for next year and the two succeeding years. The planning process includes widespread consultation.

We are now at the stage when some regional health authorities have formulated provisional redistribution proposals—I emphasise proposals, not decisions—and when some regional and area authorities have drafted plans and have put them out for consultation and comment. These plans are intended to be realistic, not just a set of aspirations. Obviously they depend very much on the resource assumptions, and particularly on the assumed extent and pace of redistribution.

I have already said that redistribution is partly to be determined by planning. The interplay of the two is a sophisticated business and it is not to be expected that it can be got right first time. So, even after the plans are put out for consultation and debate, there will be checking and re-checking and the opportunity for adjustment, and that process could take two or three years.

There have been wild stories that famous teaching hospitals in London are threatened with wholesale and imminent butchery. The hon. Members for St. Marylebone and for Ealing, Acton (Sir G. Young) made a particular point of this. This is nonsense. All that is known at present is that, if a particular pattern of redistribution was carried through within a predetermined and fairly short timescale, that could have fairly considerable implications for some of those hospitals. No one is going to work in that way. It will not happen that way, because it will take a considerable time to get this policy into operation.

Mr. Baker

Do I understand that the Minister is giving a clear and categorical guarantee that none of the 22 centres of excellence in the London area will be closed? Will he answer "Yes" or "No"?

Mr. Moyle

The hon. Gentleman is asking me to make a prediction about the next 10 or 15 years. I cannot do that. I repeat that it is absolute nonsense to think that there are plans for the imminent shutting down of major London teaching hospitals. I am not saying that there will be no closures. There will be closures of hospitals, because, as well as the re-allocation policy, there is the necessity to rationalise provision in London.

Some area health authorities have already put out formal proposals for closures and changes of use in accordance with the prescribed procedures for consultation. These are to be distinguished from the forward strategic plans. The hon. Member for Woolwich, West (Mr. Bottomley) mentioned one circumstance. My right hon. Friend the Member for Fulham (Mr. Stewart) mentioned other circumstances. I am only too happy to reiterate the statement made by my right hon. Friend at Question Time yesterday.

These other plans are designed to indicate the intended line of development and cannot lead to closures or major changes of use except through the prescribed procedures, which mean consultation with interested parties and the community health councils. There is a procedure for bringing in the regions and ultimately my right hon. Friend the Secretary of State. Ultimately there is a right of appeal to him if the community health council objects. That is why I cannot comment on particular plans—because there may well have to be an appeal to my right hon. Friend on the particular circumstances of a case and he would have to adjudicate. I should not like to prejudice his decision.

I should like to make five general observations about the strategic plans. First, they are intended to indicate possible lines of development over a long period—10 years plus. Consequently, any strategic closures which are suggested may be many years away. Secondly, they are necessarily very tentative at present. It is bound to take several years to put them into proper shape. Thirdly, they are the subject of wide consultation, which is intended to be effective. Fourthly, and crucially, they are based on assumptions about resource availability and distribution which are not yet decided upon. Fifthly, we have no intention whatever of allowing major resource allocation decisions to become a matter simply for mathematical formulae. The formulae, if accepted, will be our tools, not our masters.

Finally, I turn back to something I said at the beginning. We recognise that there are areas of acute social deprivation in inner London. Not only do they share problems common to the rest of the country, but they have many difficulties peculiar to big city life. I do not need to be told about them. Such areas exist in the London borough which I represent and in which I live. They are areas where the older housing is likely to be poor, with outside toilets, multi-occupation, suffering from damp and other deficiencies. There is a problem of heavier unemployment there than in other areas. They are areas where there is overcrowding with a shifting population, which is not a population upon which it is easy to found ideas of community care for our handicapped and long-term sick. They are areas where many of the active young are leaving for fresh opportunities and challenges elsewhere and such stable population as exists is probably an ageing one that needs more than its fair share of care.

Because inner city areas lack the amenities of life, very often medical and social care is provided on the basis of social and medical workers and doctors who live elsewhere and who enter the areas for the working day and leave at the end of it. I am aware that this encourages a tradition of hospital medication to grow up. As an example, we have already given the highest priority to building a nucleus hospital in Newham where the existing hospital service is demonstrably inadequate for the needs of this densely populated borough. It is inconceivable that a Labour Government would allow any major redistribution of hospital resources away from these parts of London without bearing in mind the need to solve problems existing in the social services and primary care.

Dr. Gerard Vaughan (Reading, South)

The Minister will appreciate the very great anxiety that exists about this matter. Can he give us a firm assurance that no centre of excellence will be closed in the near future?

Mr. Moyle

Yes.

Question put and agreed to.

Adjourned accordingly at twenty minutes to Two o'clock.