HC Deb 09 June 1980 vol 986 cc141-56
Sir George Young

I beg to move amendment No. 38, in page 3, line 3, after 'enactment', insert 'or instrument'.

Mr. Deputy Speaker (Mr. Bernard Weatherill)

With this it will be convenient to take Government amendment No. 39.

Sir G. Young

These are two technical amendments to simplify the administrative process of substituting "districts" for "areas" in statutory instruments.

Amendment agreed to.

Amendment made: No. 39, in page 3, line 4, leave out 'in consequence of' and insert 'having regard to'.—[Sir George Young.]

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Mr. Moyle

I beg to move amendment No. 3 in page 3, line 6, at end insert ' and in particular he shall refrain from making any order relating to district health authority boundaries in London until such time as a proposal for a Regional Health Authority for an area co-terminous with the area governed by the Greater London Council has been the subject of independent inquiry and report to him.'. The Royal Commission recommended an inquiry into the London Health Service. We had hoped when we were in government that the Royal Commission would give us advice on how the London Health Service which has more than its normal share of problems, should be reorganised. It did not do that. It recommended a special inquiry into the London Health Service. That was the first substantial change in the London situation after the Labour Administration left office. One of the subjects for any inquiry such as that would be whether London required four regional health authorities meeting in the centre.

The second change which has taken place since we left office and which affects London is that growth in the Health Service in London has gone. The announcement made by the Secretary of State for Social Services was that the London regions would have 0.3 per cent. extra resources in real terms in this financial year compared with last year.

That is totally inadequate. There has to be 1 per cent. real growth to cope with the increased number of elderly and to meet new medical techniques. In these circumstances there is considerable doubt whether the four cake-shaped slices of the four London regional health authorities that are designed to move resources out of London to the Home Counties can continue to function as projected by the right hon. Member for Leeds, North-East (Sir K. Joseph), who is now Secretary of State for Industry.

The consultative document rejects an inquiry. Paragraph 41 states : Much of the work necessary for taking decisions about the health services in London is already in hand. The trouble is that the work is fragmented. First, we have the Flowers report, from which the Government do their best to stand off on the ground that it is nothing to do with them. However, it is a vital document for the future development of acute hospital services in London. Secondly, we have the London Health Planning Consortium report which is related to the Flowers report. Thirdly, the Government have set up a committee under Professor Acheson to consider general practitioner services in London. Lastly, there was an announcement in the past few months of a London advisory group to consider other aspects of the London Health Service.

As these multifarious inquiries are fragmented and not comprehensive, we sought in Committee to establish the need for inquiry into the London Health Service. That attempt was rejected. If a policy for the future of the London Health Service is to succeed, it must be evolved by the people of London. They must be involved in its development and the whole policy must be sold to them. No machinery exists for either operation to take place.

We are returning to the fray because since the Bill left Committee there has been an important development. The Conservative-controlled Greater London Council has called for the institution of a regional health service for the Greater London area. It may hurt me to say so, but I find myself in agreement with the Conservative-controlled GLC to the extent that its proposal should not be rejected until there has been the most thorough inquiry into it.

The Conservatives argue that local authority views can be more easily put to the National Health Service if that form of organisation is evolved. Secondly, they argue that it would allow the cheaper administration of the service. I note that the GLC is calling for Lewis- ham to have a district health authority of its own. I entirely support that suggestion. Any desire that the Government may have to attach Guy's hospital to the Lewisham district will be fiercely rejected locally.

Mr. David Mellor (Putney)

Will the right hon. Gentleman be as forthcoming as he has been on the GLC proposals on the two other matters that he has mentioned? Many of my hon. Friends are deeply concerned about the Flowers report and the consortium report. What is the view of the official Opposition on those reports, especially as they affect Westminster hospital?

Mr. Moyle

Yes, we are deeply concerned about the two reports and our official view is that there should be no action on either Flowers or the consortium report until there has been a thorough inquiry into the London Health Service.

The London Health Planning Consortium said : Our objective has been firstly to identify a framework of major hoscpitals around which acute services should be provided in the future in a way that is responsive to population change-Secondly, the framework is intended to provide a firm base upon which the medical schools can with confidence reshape and redevelop their education and research roles. There are many people in London who would argue that that is trying to settle the issue between local and teaching hospitals before the battle has been opened. Many would argue that the real health care is given in the ordinary surburban district hospitals scattered throughout the capital. To try to make them fall in with what would be suitable for the teaching hospitals without any attempt at discussion or debate is putting the cart before the horse and missing a great opportunity.

At last we have the opportunity to question Ministers about the actions of the London advisory group. I have given notice on a number of questions that I wish to put. First, will the Flowers report, the London Health Planning Consortium report and the Acheson report be laid before the London advisory group as evidence? Secondly, will the London advisory group consider the GLC's proposal for a regional health authority for London, and will it comment on this? Will the group hear evidence from the public and invite public bodies interested in the National Health Service to give evidence?

Will the London advisory group consider the post-graduate hospitals? When we were in government we put forward proposals for the interim future of the post-graduate hospitals. If the Government want second thoughts on that, I would not regard it as a matter on which I would be prepared to go to the stake. Will the London advisory group consider the relationship of the teaching hospitals to local hospitals in London, even if it means upsetting the basic principle on which the planning consortium works?

Will the London advisory group consider the desirability of the Resource Allocation Working Party policy still being applied to the movement of resources out of London to the Home Counties? We now have an admission from the Secretary of State that the real resources for the National Health Service this year will decline for the first time for many years.

Will the London advisory group also consider the use of London hospitals by the Home Counties? There is always the argument that Home Counties hospitals are not as well provided for as London hospitals, and that is perfectly true to a large extent. Many people in the Home Counties find that it is easier to use London hospitals than local ones. For example, a major teaching hospital in London is much easier to reach for some one living in Brighton that a major teaching hospital in Canterbury because the journey across the grain of the country would be very difficult. It would be much easier for people to get on a train to London Bridge, Waterloo or Charing Cross in order to attend Guy's or St. Thomas's.

Will the London advisory group compare London social services provision with that of the Home Counties? The burden on hospitals depends substantially on the burden which the social services in any locality can undertake. It is generally believed in London that the Home Counties do not make provision out of their resources for social services in their counties on the same scale as the London boroughs because they wish to protect their ratepayers from anything other than minimal rises. This criticism must be answered if London support is to be obtained for any policy that the Government have in mind.

What will be the impact of the transfer of mental illness and mental handicap treatment from the Home Counties to inner London? Will the group be comparing London general practitioner services with those of the Home Counties? Rules of thumb are not possible here. It is possible that London general practitioners are technically thicker on the ground than general practitioners in the Home Counties. However, in most of the Home Counties general practitioner services are provided mostly by people who are in the prime of their working lives. In balanced groups in large sections of inner London, doctors restrict themselves to the minimum National Health Service lists in order to leave the maximum room for private practice. I know to my cost that a number of them occupy surgeries in premises that are an indictment of the medical profession. It is not easy to compare like with like. It is a job for the London advisory group.

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Then there is the discontent in the London ambulance service. Many assert that it is unable to compete in the labour market, that it has never been given its rightful status as an emergency service and that its structure prevents efficient running by providing no accountability or responsibility. It is said that consensus management, of which the London ambulance service is an example, militates against efficiency. Again, a reduction in resources will make the situation worse.

Is it feasible to transfer resources from the acute sector to community services? In much of London the practice is for people to resort to the teaching hospitals instead of seeing their general practitioner. Many inner London social services are under great pressure because of housing and social conditions, ethnic minorities and so on. All the community services need to be strengthened. One source for that may be the existing acute services, where beds appear to be in large numbers.

Finally, and perhaps most crucially, will Government action on the reorganisation of the London Health Service be delayed until the London advisory group has considered all those points and produced a report and recommendations for public debate and discussion? That is what we want. The reorganisation will doubtless be centred around the idea that there should be a regional health authority for London. We want full consideration and public debate of all the problems before the Government take action. Londoners must be carried by any policy propounded for London's health services. At present that is not so. They are worried. They see hospitals being closed and do not know why.

People say that other parts of the country are not as well off as London, yet Londoners know that in many cases their general practitioner services are inadequate and their social services are under considerable pressure. They will want all that taken care of.

Finally, turning briefly to the Westminster, King's and Royal Free hospitals, we especially say that no action should be taken on the future of those famous hospitals until the inquiry report is available. That answers the point raised by the hon. Member for Putney (Mr. Mellor).

Those are the official views of the Opposition. We look forward to hearing what the Minister has to say about the questions that we have posed.

Mr. Ennals

I warmly support the proposal for an independent London inquiry and agree with all the arguments advanced by my right hon. Friend the Member for Lewisham, East (Mr. Moyle).

I wish to develop only one argument. Many hon. Members are deeply concerned about the danger of possibly damaging proposals for the reorganisation of medical education in London, and in particular the future of the Westminster medical school. Why should any responsible group plan its closure? It cannot be on grounds of costs. It costs less to educate a medical student at King's College and Westminster than anywhere else in London. The total cost of training a doctor over five years at Westminster medical school is £14,000, and at St. George's hospital medical school it is almost £30,000. The average cost for all the London schools is about £22,000.

The proposal cannot be justified on the ground of performance. It is generally accepted that Westminster is, in every sense, a centre of excellence. Its academic record certainly proves that. The vice-chancellor wrote to the dean of the medical school at Westminster : If one takes the final medical degree examinations at first attempt, Westminster Medical School is top of the list with an average of 88.5 per cent. passes over the 10 year period 1970–79. Subsequent figures were published in The Lancet on 10 May. The final MB results of Cambridge university students trained at the London Medical schools showed Westminster high among the distinguished students at 6.2 per cent., compared with 1.4 per cent. from St. George's, 1.7 per cent. from the London, 2.6 per cent. from Guy's and 41 per cent from Bart's ; second highest among those who passed and with by far the lowest figure of failures at 51 per cent., compared with 24.3 per cent. for St. George's, 21.6 per cent. for Bart's and double figure failure rates from Guy's, King's, the Middlesex, St. Mary's and UCH. I am not running down any of the others ; I am simply trying to find out why anyone should propose that the Westminster medical school should close.

One reason why the Westminster medical school is so good is that it is small. Relations between the academic and student bodies are close and it is an endorsement of the view that small is beautiful—a thesis that runs contrary to the recommendations of the Flowers report.

It would be unthinkable and academic vandalism to close the most successful of the London medical schools for the sake of administrative tidiness or for any other reason put forward in the Flowers report. I was glad to have an assurance from my hon. Friend the Member for Lewisham, East that the Opposition Front Bench believe that no such decision should be taken until there has been a further inquiry into all the problems of the services in London. Certainly at the Westminster we have a school which produces not only doctors, but research work of a high standard.

We have to ask why the proposal has been made. The vice-chancellor of the university said in the hearing of a number of hon. Members from both sides who are in the Chamber that proposals to close the school would have been contemplated only if it were known that there would be a substantial reduction in the number of acute beds at the Westminster. The assumption was that the recommendations of the London Health Planning Consortium would be carried through, that 410 beds would go and that the Westminister would be left with 100 beds and no basis for a medical school.

The Secretary of State has made it clear that no decision has been taken on the recommendations of the consortium. The Kensington, Chelsea and Westminster area health authority (teaching) has concluded that for service planning reasons—not educational reasons—the Westminster hospital should not be reduced to 100 beds as recommended, but that 350 acute beds should be retained, and that the remaining capacity might be used for a small postgraduate institute. Obviously that problem is an essential task for an inquiry.

Another argument takes the matter beyond the Westminster to the broader scope of the Flowers report. It concerns the size of units. I have grave doubts about the arguments used in the Flowers report to justify medical schools under a single management structure. The success of the Westminster medical school provides impressive evidence of my view.

The proposals would result in the creation of large medical schools, at least two of which would be larger than any other in the United Kingdom. Many academics, including some from large provincial schools, have serious misgivings about medical schools of such a size. The deans of the provincial medical schools have said : It has been the common experience of expanding Medical Schools that the quality of medical education has suffered significantly and progressively as the annual intake has risen above the figure of 100.120 which we consider to be a far more satisfactory size of entry. We were interested to learn that in the United States the average figure is 133. The Royal College of Physicians takes a similar view of large medical schools. It says : Small group and even individual teaching is to be encouraged, and this may be achieved by the use of associated hospitals, and by secondment of students for part of their course to peripheral hospitals where they can be given more personal responsibility. We see considerable virtue in allowing individual teaching hospitals to retain their identities ; but equally we recommend co-operation, or even federation between them, so that the entire range of clinical academic disciplines may be covered without expensive reduplication. This possibility has not so far been adequately tested in London, and this should be done before large-scale mergers are imposed. This is only one argument for a thorough inquiry into medical education within the context of all the provisions of health, medical and educational services in London. I hope that the Minister will confirm the point made by the Secretary of State on other occasions, namely, that no decision has been taken about what will happen in terms of cutting the number of beds. It would be madness for the university to proceed to a decision on the whole pattern of medical education in London that affects some of the finest medical schools, not just in London, but in the world. For any such decision to be taken before there has been a proper inquiry would be almost criminal.

Mr. Mellor

I am glad to have the opportunity to contribute to a debate on London health services raised by this interesting amendment. Throughout my brief time in this place, the problems of the London health services have been an almost constant preoccupation, not because I have so wished but because of circumstances that have arisen both in my constituency and through my other interests as a special trustee of Westminster hospital. I should make clear, so that my observations are not misunderstood, that nothing that I shall say is intended to be critical of the Minister, who, on many occasions, which both he and I know about, on constituency matters relating to hospitals in my constituency, has been most supportive and helpful. I pay tribute to his assistance and to his clear dedication to the London health services.

It is equally right that what I say should be regarded not as a criticism but as an exhortation to yet greater effort to see, as clearly as I see, through my contacts with the Westminster hospital, and in other ways, the areas of concern that have built up and the need for positive further action by the Government.

I should like to take up the speech of the right hon. Member for Norwich, North (Mr. Ennals) about Westminster hospital, although that represents only one part of the remarks I wish to make. I do not wish to repeat what I said in an Adjournment debate that I raised on this subject some months ago. I prefer to move on. It is disappointing that on many occasions—not just in that debate but as recently as Question Time last Tuesday, when my hon. Friend the Member for Peterborough (Dr. Mawhinney), the right hon. Member for Norwich, North and I expressed in categoric terms what we know to be the position of London university on the Flowers report—there has not been a greater explanation of the Government's position than that given by my hon. Friend the Member for Ealing, Acton (Sir G. Young) that the Government did not wish to be associated with the consortium report in relation to Westminster hospital. They were, nevertheless, taking refuge behind the suggestion that this was a matter for an advisory group. I cannot pretend to find compelling a situation whereby a consortium report of an advisory nature is put out to yet another advisory group to give advice that, in the fulness of time, will be assessed by the Government.

That might seem all right on the whole if the main concern was to avoid a decision being taken. But the tragedy is that there is this failure on the part of the university to address its mind to the central issue. I appreciate that my hon. Friend inherited the consortium report. He is not responsible for it. He did not commission it. It has landed on his table. I sympathise with him, and I do not want anyone to think that he is to blame for the consortium or its report. However, I do not believe that it is a tenable position for the Government to say that they will await the result of the advisory group's comment on this other advisory report at a time when it is on the record and has been said in this House so often that it has become almost tedious to repeat it that London university will make its decision in July on the basis that the consortium report is likely to prove compelling to the Government and likely to be accepted.

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Taking it from that standpoint one can hardly blame the vice-chancellor of London university for asking what is the point of continuing to propose that medical education be continued at the Westminster when, for all it knows, within 12 months a hospital within which those people can be taught may not continue to exist in any meaningful sense.

Mr. Ennals

I agree with all that the hon. Gentleman has said so far, but does not he agree that in a sense the problem is worse confounded by the thought that we cannot have a debate in this House, other than on an amendment to a Bill, until the university has taken its decision? That may be a matter to which the hon. Gentleman will be coming, but it seems that Parliament ought to express its view.

Mr. Mellor

I agree with the right hon. Gentleman that there is a sense of impotence about this matter which I find most disturbing.

I ought to say to my hon. Friend that some of us would find it very hard to forgive, putting it as neutrally as I can, if, as a result of the Government not making their position clear, London university went ahead and ratified the Flowers report and destroyed its teaching hospital, and the Government then said that it was none of their doing because they had not led the university to take the view that it did.

I am sorry to say that, although there were some parts of what my hon. Friend the Under-Secretary of State said in answer to questions last Tuesday which were encouraging, they were hedged around with these qualifications. What he was really saying was that it could not become Government policy until what the advisory group had to say had been considered. That was not a disavowal in the terms that I want to see and, before it is too late, I urge the Government to say something which will make it clear to London university that if it is to act on Flowers and commit an act of intellectual Luddism of a kind which is not paralleled in any other case that has come to my notice, it should do so for reasons other than hiding behind the fact that it believes that the Government will rely on the consortium report.

I serve notice that it will be very difficult for many of us in this House to feel that the Government will not bear responsibility for Flowers. They cannot simply say that it is a matter for London university if the opportunity to disabuse it of the great delusion under which it labours is not taken before it makes its decision.

I move on to the consortium report. I regret bitterly the policy followed by the previous Administration of moving resources out of London not because I have any reason to think that everything should be centred in London, even though I am a London Member, but because I do not believe that the destruction of institutions in London which inevitably will follow from such a policy will result in the creation of more facilities elsewhere. I associate myself with the argument advanced by the Opposition. In any event, the London teaching hospitals serve an area far wider than London. They go out as far as the country stretches.

I should like to repeat to the House one very moving example of that which came to my notice this afternoon. It arose purely fortuitously on a visit to Westminster hospital today by the special trustees. The visit was not arranged because of this debate. We spent the afternoon touring the hospital and looking at different parts of the building that were in need of the additional finance that we have at our disposal to allocate.

One of our visits was to the new Barrier nursing project at the hospital. That project, designed to cure leukaemia involves the destruction of all the cells in the marrow and their replacement with new cells. That treatment has so far had a 50 per cent. success rate.

We had the opportunity of seeing the treatment in operation and of considering whether we could make extra funds available to enable the resources devoted to this major and crucial work—important not just in this country but throughout the world—to be carried on. May I ask, in parentheses what would happen to that work if Westminster hospital were to become merely an annex of St. Thomas's hospital?

There was a patient who had just been given a transplant and who was in isolation for four weeks in an infection-free environment while the treatment took effect. While the doctor was expatiating upon this wonderful new process I asked him where the patient came from, and he said that the patient came from Cardiff. The next person to move into that bed when the current patient leaves comes, ironically, from Reading—an area well known to my hon. Friend the Minis- ter. That example, establishes beyond peradventure that this centre of excellence is not just an asset belonging to London or to that particular depopulated part of London. It is an asset that hon. Members make use of from time to time, but it is also a national asset.

However one tries to dress it up in the fancy language of the consortium about the need to equalise services up and down the country, no one can tell me that, suddenly, as a result of closing Westminster hospital a unit will spring up in Cardiff that will give hope to that young girl of 18 who is otherwise suffering from terminal leukaemia. That will not be the case and I hope that my hon. Friend will find it within his compass tonight to disabuse that report at least so far as it applies to Westminster hospital.

I am not in favour of a lot of further inquiries but I recognise that this may be a convenient device for us to discuss the problems of London. I cannot pretend to be persuaded that another inquiry on the subject of London health treatment will be effective. I take the view that the London health services need to be recognised for what they are, for the problems that they face and for the contribution that they make to medicine not just nationally but internationally as well.

I do not wish to go on at inordinate length, but I wish to say a word or two about reorganisation. The central aim of the clause is to allow the dissolution of the area health authorities. I would welcome that since it is clear that the three-tier system has not worked well. I urge my hon. Friend, when he considers what to do in London, to ensure that the minimum amount of further disruption is caused particularly at district level. There are a number of health districts in London that fall below the population recommended in the consultative paper "Patients First".

I have been encouraged by conversations with my hon. Friend about Roe-hampton health district which, with a population of 110,000, is much smaller. But I ask him to say that, where there is a district with an efficient and effective district general hospital and where that hospital works well for its catchment area even if that situation does not fit in with the new jargon word "co-terminosity"—which I cannot pretend to like or fully to understand—that health district should be permitted to survive. I am grateful for my hon. Friend's sympathy in other places on that point.

I make one point about the future of regional health authorities in London. My argument about minimum disruption may go against what I now say but I also cannot pretend to be persuaded that it was ever a good idea for us to slice London up into four segments in the way that was done. I cannot pretend that I believe that it has worked well. On the whole I think that there is much in what is proposed by the GLC. This may not be something which should be rushed, but I hope that it will be given the most serious consideration. I cannot pretend to be happy about the way in which the present regional health authority has worked in London. A structure that allows London to be considered as a whole might be better.

Mr. Dubs

The logic of what the hon. Member for Putney (Mr. Mellor) said suggests that he should support the amendment. If we do not manage to achieve a sensible organisation for the Health Service in London now, it will be many years before we have another opportunity. If the Government go ahead and set up the new district health authorities on the basis of the existing pattern of the National Health Service organisation in London, it might be a decade or more before we can think about a different pattern. I support the call for an inquiry.

I am conscious that London faces many difficult problems. There is much uncertainty among the people who work for the Health Service in London. Reasons for the uncertainty include RAWP, introduced by the last Labour Government, cuts in spending and closures. It was made worse by cuts consequent on the increase of VAT. Uncertainty was also injected into the provision of hospital services in London by the Flowers and consortium reports.

There is a doubt about which teaching hospitals will survive. There are doubts about the relationship between undergraduate teaching hospitals and postgraduate teaching hospitals. There are doubts about whether post-graduate teaching hospitals are to become part of the new pattern of district health services or whether they are to remain separate.

A recent consultation paper, "The Future Pattern of Hospital Provision in England", suggests that we should move towards smaller hospitals. Paragraph 28 of that document refers to retaining in a variety of useful supporting patterns, more of the other hospitals than had previously been expected. That adds a further element of uncertainty to the pattern of hospital provision in London.

The Health Service in London has the unparalleled difficulty of a large commuter population which is dependent on the inner London hospitals and a large number of visitors to the capital who require Health Service facilities. In the inner part of London there is a declining population, but it has an increasing elderly element which puts a different demand on primary care services and hospital facilities in the capital.

There are four regional health authorities which take cake-like slices of the capital's resources and extend into the leafy suburbs and beyond. Each regional health authority faces the problems of deprived inner city areas and the problems of the green belts. The regional health authorities must decide how to allocate resources when faced with the conflicting demands of inner city deprivation and of expanding suburban and almost country populations and their needs for increased health provision. It has proved difficult—virtually impossible—for the regional health authorities to resolve this very difficult problem of resource allocation, given the conflicting pressures.

It is also true to say that the Health Service in London suffers from greater problems of relationships with local authorities than is the case elsewhere—not because there is an unwillingness to co-operate but because the boundaries make such co-operation much more difficult to achieve effectively and harmoniously. That causes problems, not only in joint financing, where many of the committees set up to deal with the bids have to—

It being Ten o'clock, the debate stood adjourned.

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