HC Deb 23 October 1992 vol 212 cc696-710

11 am

The Secretary of State for Health (Mrs. Virginia Bottomley)

With permission, Madam Speaker, I should like to make a statement about the publication of Sir Bernard Tomlinson's advice on the future of London's health services.

The House will recall that a year ago the Government asked Sir Bernard and a small team of experts to carry out an inquiry into health services, medical education and research in London. The inquiry had a wide remit and addressed complex and long-standing issues. The central problem is that, over a period of decades, London's health service has become increasingly poorly matched to the needs of Londoners. The Government are determined to tackle that problem, and with that in mind we asked Sir Bernard to proceed.

He was asked for a strategic view of London, working with the grain of the new NHS, and to look not only at the hospital service, but at primary health care and the organisation of medical teaching and research.

Sir Bernard has now submitted his report to my right hon. Friend the Secretary of State for Education and myself. We are publishing it today. Copies have been placed in the Vote Office and sent to health authorities, the university of London, and to the many professional and other bodies having an interest in its findings.

I place on record our thanks to Sir Bernard and his team for the very considerable effort that has gone into the inquiry and for producing so thorough and comprehensive a report.

The report does not offer any easy solutions to problems that have bedevilled policy makers and professionals for years. It is wide ranging and contains many detailed recommendations. Its key findings are that the current pattern of acute hospital provision in London is both undesirable and unsustainable and that it requires substantial modification to meet the current and future health needs of Londoners; that medical education and research need to be organised along different lines, to maintain and to strengthen London's status as a major national and international medical centre; that primary and community health services are comparatively poorly developed in London and that resources need to be reinvested from the hospital sector into these services to bring them up to the standards common in other places.

The Government welcome Sir Bernard's broad conclusions, which are in line with earlier reports—such as that from the King's Fund. I must stress, however, that his report is advice to the Government, not Government policy.

I am sure that the report will be widely and keenly debated. We welcome that. We will listen carefully to the views expressed. Indeed, I have asked my hon. Friend the Minister for Health to visit the institutions potentially most affected to discuss at first hand the ideas set out in the report.

When we are satisfied that we have heard all points of view, we shall respond by setting out our detailed proposals on changes in the NHS. I anticipate that that will be early in the new year. In bringing forward proposals, our prime consideration will be to safeguard and improve health care for Londoners.—[interruption.]These are important matters, and I shall be grateful if Labour Members will listen to the detail.

We shall ensure also that full account is taken of the implications for NHS staff working in London, and of the need for joint planning with education and research interests of NHS changes that affect them. I can assure the House that no major decisions will be taken without proper consultation using the well-established, existing NHS procedures. However, the Government accept the widely accepted view that London has too many hospitals and too many beds. Change is essential if we are to avoid the risks highlighted in the report of a spiral of decline in London's hospitals, and if we are to secure the benefits of a switch to more primary and community care.

There are, in addition, some immediate issues concerning the four trusts—Bart's, King's, St. Mary's and St. Thomas's—which have already been constituted, but which do not come into full existence until April 1993. Sir Bernard's report makes specific recommendations about those trusts.

In order to put ourselves in a position to decide their future configuration in the new year, I propose that consultation in respect of the Bart's, King's and St. Thomas's trusts be initiated in line with Sir Bernard's recommendations. The report raises no major issues relating to St. Mary's, and that trust will proceed as planned from April 1993.

In the case of St. George's—an applicant for third wave trust status—we will initiate consultation on a revised configuration, separating acute and community services. Again, that is in line with Sir Bernard's recommendations. I stress that those will be consultations about the future configuration of the management of the hospitals. They do not imply prior acceptance of the report's recommendations about sites.

The report makes a number of important recommendations about medical education and research, and they centre on improving the quality of medical education and research by amalgamating London's medical schools and, in the longer term, postgraduate institutions into four multi-faculty colleges of London university.

My right hon. Friend the Secretary of State for Education and I believe that the broad principles underlying those recommendations will remain valid whatever detailed pattern of NHS change emerges after the statutory consultations. He has therefore written to the chairman of the Higher Education Funding Council for England indicating his broad support for the report's conclusions on medical education and research. My right hon. Friend has invited the HEFCE, working with the university of London and the other bodies concerned, to take forward implementation of the proposals.

The Government intend to act immediately on two of the report's other recommendations. First, we have decided to establish as soon as possible a special London implementation group to carry forward work arising from Sir Bernard's report. The group will be part of the NHS management executive and will involve the HEFCE. It will be chaired by Mr. Tim Chessells, who will, of course, give up his current post as chairman of North East Thames regional health authority. Mr. Chessells will co-operate closely with the four Thames regional chairmen. Further details of its remit and membership will be announced in due course.

I stress that the group will be concerned with implementation of the policy, not policy-making. I decided that it would be wise to establish the group beforehand, so that it does not start cold from the date that I announce my decisions. There is work it needs to do before then— [Interruption.] These are important issues and, although I hope that Opposition Members will be able to give their views, it will be helpful if I may be allowed to complete my statement.

We accept also the report's advice that urgent further work is needed to review the disposition of several specialist services across London. I shall be asking the implementation group to set in train those specialty reviews as its first priority. In carrying forward that work, we shall ensure that London's world-class centres of excellence in treatment, teaching and research are clearly identified and safeguarded.

It is perhaps inevitable that attention will focus on the report's recommendations about hospitals, but it would be wrong to concentrate on those to the exclusion of the recommendations about primary and community care, and about services for the mentally ill and those with learning disabilities. The decisions taken on Sir Bernard's report must be seen as a whole, as part of a new and better approach to the provision of health care for Londoners.

Many people, across political parties, and including the British Medical Association and the King's Fund, agree on the need to improve and restructure London's health services. Achieving the changes necessary will mean some difficult choices. The Government's overriding aim is to improve the health services in London and for Londoners. It is on that basis that, after careful consultation, decisions on Sir Bernard's report will be taken.

Mr. David Blunkett (Sheffield, Brightside)

First, let me thank the Secretary of State and her office for arranging for the statement to be transcribed into braille.

The statement represents a lost opportunity. It is the first real challenge that the Secretary of State has had to take on since she took office earlier this year, and I regret to say that it fails according to every criterion. Why does it contain no reference to paragraphs 30, 48 or 227 of Sir Bernard's report, which deal with the investment that is needed in London's health care—hospital and primary care—to bring it up to an acceptable standard? The report and the statement, by implication, accept that the present standard is unacceptable.

Why is there no reference to ring fencing the existing resources that are being spent in London? Why is there no commitment to protecting London's health care—London's investment—from the ravages of the Chancellor of the Exchequer in the autumn statement on 12 November? We can only assume from the statement that the Secretary of State has already given in on the question of resources, and that her proposals—her interpretation of Sir Bernard's report—will be an excuse for cuts, rather than for the future investment that is needed.

Does the Secretary of State accept that the reversal of the internal market and the commercialisation of the health service are a prerequisite for the ability to put London's health care back on its feet? Does she accept that the protection of the specialties mentioned in the report and the statement cannot be achieved by their integration in the internal market—that it can be achieved only by their integration in a planned and coherent health service for the future? Does she agree that the establishment of a health authority for London is a vital prerequisite for the planning of changes, and for future investment in primary and community facilities in the capital?

Why is there nothing in the statement—bar a passing reference to "primary health care"—that would make anyone at all confident that the Secretary of State really believes that it is necessary to invest new resources in building up those inadequate facilities? Why does the statement make no mention of the need for improvement in accident and emergency facilities in the community, and in out-patient departments? Why has it nothing to say on such vital issues as how we are to invest the resources, and the time scale over which the changes will be made? Why was the Secretary of State unable to outline to the House the terms of reference of the implementation group, or its membership? The Secretary of State has had Sir Bernard's report for a long time, and the terms of reference are crucial to whether anyone in London or the country as a whole can believe a word that she says about good intentions towards the health care of the capital.

Will the Secretary of State acknowledge that the Government's actions over the past decade have turned a problem into a crisis for London's health care? Does she accept that consistent underfunding, lack of planning and gross neglect of primary and hospital investment lie at the heart of the problem with which the statement deals? Will she extend the totally inadequate consultation period to allow real participation by the people whose voice is seldom heard in the clamour of professional experts and vested interests—the voice of the people of London themselves?

Does the Secretary of State understand that, although Opposition Members understand that the status quo is not an option— [HON. MEMBERS: "Ah!"]. The inadequate health care of the people of London is not an option, and that is what the status quo would mean.

The protection of the health service, the jobs of health workers and the safeguarding of any promises that are made will be the Opposition's absolute priority. We have set out our criteria. We have countenanced no closure and no change in service, unless and until those criteria are met. This morning's statement meets none of them; it achieves none of the goals that have been acknowledged by many people to be a vital part of putting London's health care on its feet and building confidence in the future.

We are here not to dig the Secretary of State out of a hole of her own making, but to protect the well-being, the health care and the health workers of the people of London; and that is what the Opposition will be doing in the months ahead.

Mrs. Bottomley

What we have just heard is the ranting of a NUPE-sponsored spokesman.

Sir Bernard's report—which I hope all hon. Members will read in great detail—identifies over-provision that has taken place in London for many years. There are, for instance, more acute beds in London—3.9 per 1,000 people compared with 2.5 per 1,000 in other parts of the country. Spending on London's acute services amounts to £260 a head, compared with £173 in other cities. Some 20 per cent. of health service resources are spent in London, which contains 15 per cent. of the population.

The Opposition always come up with the same knee-jerk reaction that nothing can be solved without a larger cheque book. In the report, Sir Bernard states: In 1992–93 spending per inner London resident on hospital services, after weighting for morbidity and mortality (which adds about 5 per cent.), and allowing for excess London costs, will be 20 per cent. greater than the average for England. The problems of the inner London hospitals are plainly not due to overall lack of resources. What we are considering—and it is a sensitive and complex matter—is how we can ensure that London services are matched more effectively to the needs of Londoners. The great institutions—the teaching, postgraduate and acute hospitals, which go back for many years—are no longer appropriate to a health service where hospitals all over the home counties are able to offer advanced and sophisticated treatment. At the same time, the community services have not been adequately developed.

Clearly, the proposals have resource implications. When I return to the House in the new year to inform hon. Members of the decisions that we have made in regard to implementing the recommendations, I shall of course make the resource elements clear. At this stage however, the proposals constitute Sir Bernard's advice to the Government; they are not yet Government policy.

Sir John Wheeler (Westminster, North)

My right hon. Friend will know that the news that St. Mary's hospital trust is to proceed is welcome news to my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke) and myself. The good work of that hospital is already widely recognised.

Will my right hon. Friend confirm that her statement is not about cuts in London's national health service provision, but about restructuring and improving the service? What action does she intend to take to bring home to the people of London the nature of the review, as opposed to the disinformation that will undoubtedly flow?

Mrs. Bottomley

I am grateful to my hon. Friend, and also to my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke). I was able to make that announcement about St. Mary's, but I know that many of their constituents use other hospitals in the capital.

It is important for us to take this opportunity to engage in an enlightened discussion of the challenges contained in the report. It is about the 20th report on London's health services to appear over the past 100 years. I am encouraged by what so many commentators, from the British Medical Association and even the NHS Support Federation, which is a politically motivated group that supports the Labour party, have said. Julia Schofield the director of the NHS Support Federation, said: It probably is the best decision to close one or more hospitals. It is important we have a reconfiguration of services, making it clear that the aim and the objective is improved health services for Londoners.

Mr. Brian Sedgemore (Hackney, South and Shoreditch)

Is the Secretary of State aware that her grandfather, who was a medical student at Bart's, is today turning in his grave because of the extraordinary act of betrayal by his granddaughter in the House? Does she not understand that Londoners will not let her close Bart's and that she has engaged upon a battle that she cannot win? If she does not believe me, will she go to the hospital today and see the tears of the patients?

Mrs. Bottomley

My grandfather, who trained at Bart's and then went on to be a single-handed general practitioner in Chester, would have been enormously impressed by the developments in primary health care all over the country. There is concern, however, about London, where still more is spent, officially, per head on family health service specialties but where there is not a sufficiently advanced service available for Londoners. We have more GPs who are over 65, more single-handed GPs, fewer practice nurses and poorer community services, with fewer district nurses. I have no doubt that my grand father would support the proposition that we should not hold on to institutions but should think of health services—but, of course, patients first, also education and also research.

Mr. Matthew Carrington (Fulham)

My right hon. Friend will know that the proposal to change the nature of or to close Charing Cross hospital will be met with considerable suspicion and much opposition. It will be hard to convince people that the closing of that hospital will improve health care in west London. When my right hon. Friend reviews the Tomlinson report, will she take into account the vital need to maintain, at the very least, the accident and emergency and primary health care facilities on the Charing Cross site?

Mrs. Bottomley

I well understand the great loyalty that every individual constituency Member of Parliament has to his or her own particular institutions, but, with 45 acute hospitals serving 250 beds or more and with 12 major undergraduate teaching hospitals, it is clear that there has to be change. My hon. Friend has made some extremely important points about Charing Cross. When my hon. Friend the Minister for Health visits the hospital to discuss the proposals and to consider the way forward, I shall make sure that he takes particular note of those points of concern that have been raised by my hon. Friend.

Mr. Simon Hughes (Southwark and Bermondsey)

Nobody doubts that the health service in London needs a shake-up, but I am sure that the Secretary of State is aware that some of the things that she has said will cause concern rather than comfort, not just to those who live in London but to those who work in London and visit London and use the health service. All services across the public sector cost more in the capital city than elsewhere, per head of use. I am sure that the Secretary of State is aware that there is a great need for the transfer of resources to primary and community care, but unless the reforms mean that when people who live in London need a hospital bed they can get one, and that when people who live in London need an ambulance they can get one and do not have to wait six hours for it, and that when people who live in London have an accident they can be admitted to an accident and emergency department, and that when people who live and work in London find that instead of a statistical analysis of how many beds are needed there is a proper working out of how to meet the daily needs of that part of the country which, paradoxically, serves its people least well., the people whom the Secretary of State seeks to serve will be caused the greatest worry. At the moment we have worry. It is up to her to make sure that she listens and ensures that the resources are there to improve services, not to make them worse as a result of these radical proposals.

Mrs. Bottomley

There is nothing that the hon. Gentleman has said with which I do not heartily agree. They are all very important points. All of them are aspects which we shall consider when we hold our consultations on the proposals. However, the hon. Gentleman knows full well that his constituency is served by three outstanding hospitals—King's, Guy's and St. Thomas's. He knows as well as anybody who is remotely informed about the health service in London that it is not possible for all three to continue without changes. The sense of uncertainty is very damaging for morale. It is right that we should grasp the nettle and consult and that we should take decisions. There is no one who, in any half-informed way, thinks that the situation can or should continue as it is. Propping up the acute services often starves the community services. We have to take decisions that will bring an end to the uncertainty for staff and which, above all, will lead to a better health service for Londoners which meets exactly the criteria that the hon. Gentleman identified.

Mrs. Marion Roe (Broxbourne)

After many weeks of uncertainty, speculation and rumour, I am pleased that at last the Tomlinson report has been published. There is no doubt that during the consultation period my right hon. Friend will be lobbied by those who are affected by the proposals. However, I ask her to bear it in mind that in my Hertfordshire constituency there has been concern for many years that our local hospitals have been disadvantaged because London hospitals have been demanding too great a share of the resources available. [Interruption.] We are all looking after our constituency interests. That point must be made. I remind my right hon. Friend that my local hospitals are treating former Londoners who have moved out of the capital. They also deserve to be considered.

Mrs. Bottomley

My hon. Friend is exactly right. There are hospitals throughout the home counties that wish to treat patients who traditionally were sent to London. In the home counties we have encouraged those health authorities in the outer London ring to continue this year with the traditional patterns of referral, but it makes no sense to continue with a pattern of referral, unless it is what the patient wishes, simply to prop up institutions because nobody has been brave enough to make the necessary decisions. My hon. Friend speaks for very many throughout the home counties who say, "Please can we now reorganise the health service to meet the needs of the population today and tomorrow, not those of the last 50 or 100 years?"

Ms. Kate Hoey (Vauxhall)

May I tell the Secretary of State that the report and her statement will be received by the users of London's health services with anger, horror and fear—fear in the area that I represent, where some 728,000 people who work and live in the area served by St. Thomas's know about the waiting lists in that area and cannot, therefore, see any justification whatsoever for even contemplating closing or merging St. Thomas's and Guy's hospitals. If St. Thomas's accident and emergency service closes, the Secretary of State will make Londoners move around in ambulances and die in ambulances in London's traffic jams on their way to hospital.

Mrs. Bottomley

I do not accept what the hon. Lady says. When she studies the report she will see that it makes special mention of the Lambeth community hospital, which she has brought to my attention in the past. The report makes it clear that, for that small area to have such an intensity of acute services, without sufficient community services, is inappropriate. She will know how her constituents frequently use an accident and emergency centre instead of using a GP resource; there is a need to bring forward development in that area.

As I told the hon. Member for Southwark and Bermondsey (Mr. Hughes), knowing the area well, I believe that the staff know full well that the situation cannot continue and that, above all, what people want is a decision. In an editorial, The Guardian, said: Only political ostriches would refuse to recognise these facts. London's health service consumes more money than anywhere else but provides its citizens with a worse deal.

Dr. Charles Goodson-Wickes (Wimbledon)

I congratulate my right hon. Friend on the inevitable, if uncomfortable, logic of her argument. Decisions on these matters have been postponed for far too long. Will she assure the House that alternative medical use of Bart's, which has been a centre of international medical excellence for the past nine centuries, will be explored before the recommended disposal, to ensure that its long-standing traditions can continue, consistent with today's changing health needs?

Mrs. Bottomley

I can only assure the House that our decisions will be determined, above all, by the needs of patients. Their needs must come first, but the Tomlinson report makes it clear that education and research occupy a similarly important position. We must make decisions according to those criteria. There is no doubt that hospitals in locations where the population has moved away are having great difficulty matching their activity to their resources. Bart's is certainly one such institution. Nobody will make decisions on any of these matters lightly. My hon. Friend the Minister for Health will visit Bart's and the other crucial sites to discuss the way forward. I have already announced that we shall consult on the merged management of Bart's and the Royal London hospital, but that does not prejudge long-term decisions on the sites.

Mr. Peter Shore (Bethnal Green and Stepney)

The right hon. Lady's failure to mention in her statement the crucial question of resources and her subsequent quotation of the opinion of Sir Bernard Tomlinson that London was over-provided in terms of finance will be greeted with dismay and cynicism throughout London. No adequate evidence has been produced for that assertion, and almost everyone who has hospital connections fears that the Government will use the allegation that there are too many hospital beds in London to cut basic health services under the guise of switching resources to primary care. She placed much emphasis on the centres of excellence. Will she assure us that at least one of the centres of excellence in postgraduate medicine that deals with heart and lung disease, which is a high priority in the nation's health—the special health authority which includes the Brompton and the London chest hospital in my constituency—will be preserved and not forced into an unwanted merger with adjacent hospitals?

Mrs. Bottomley

I am saddened that the right hon. Gentleman should present the report in that context because he is well informed about the long-term dilemmas facing the London health service and about the excessive provision of institutions. I am sure that he is well aware of the independent King's Fund report, which considered even more dramatic changes than those outlined in the Tomlinson report. I cannot make any announcements except that we shall consult on the proposals. These are Sir Bernard Tomlinson's proposals, not Government policy. It is proposed that the London chest hospital should work with the Royal London because of the view that single-specialty centres increasingly benefit from a close association with a hospital where all the other specialties are available. That, again, is a matter on which there will be further discussions.

Mr. Harry Greenway (Ealing, North)

When considering provision in outer London, will my right hon. Friend take full account of the very important links between, for example, a community such as Ealing and Ealing hospital and do all that she can to shake up the emergency and ordinary sections of the London ambulance service, which are causing enormous distress to many people and which need enormous improvement? If such improvements resulted from the review, it would be most valuable.

Mrs. Bottomley

The health care needs of my hon. Friend's constituents and those across London will be a high priority in reaching decisions. My hon. Friend asked about the London ambulance service, which was not considered by the Tomlinson inquiry. There has been much investment in a new computer system and vehicles and increased resources. Like my hon. Friend, I am determined to see an improvement in the standards that are achieved.

Mrs. Bridget Prentice (Lewisham, East)

Would the Secretary of State like to comment on paragraph 125 of the report, which deals with St. Thomas's and the Guy's and Lewisham trust? Sir Bernard makes it quite clear that, in his view, Lewisham hospital should have a secure future. I hope that the Secretary of State agrees with that. Where does that leave Lewisham hospital if the amalgamation of St. Thomas's and Guy's goes ahead? What will be its status?

Mrs. Bottomley

The proposal in the Tomlinson report is that Lewisham hospital should become a NHS trust on its own, leaving Guy's and St. Thomas's to be managed jointly. We shall consult on the report's proposals, and no firm decisions will be taken until we are satisfied about the outcome of that consultation. I remind the hon. Lady that, before the establishment of any NHS trust, the primary conditions must be that the trust will lead to improved services for patients.

Mr. John Marshall (Hendon, South)

Will my right hon. Friend confirm that we are talking about a reallocation of resources in London and not a reduction? Does she accept that many people in London want to see better general practice and more resources put into the care of mental health patients? Does she accept that there has been a movement of population out of central London to the surburbs and that outer London boroughs want more and not less?

Mrs. Bottomley

My hon. Friend puts the case correctly. An editorial in The Times said: Londoners need basic, unglamorous health care from GPs, nurses and community health centres. That can only be paid for with the money raised by making London hospitals better suited to the needs not of their doctors but of their patients. That has been known for decades.

Mr. Tom Cox (Tooting)

The Secretary of State must be aware that, week by week, every London Member receives ongoing complaints from constituents about the lack of services and about waiting times and waiting lists. So much for her comments that we are overprovided for in London. If the proposals that she has announced today are implemented, they will be disastrous for the people of London. She specifically mentioned St. George's hospital in my constituency, which is not threatened with closure, but yet again faces reductions in expenditure and bad provision. I take very much the point that was made by the hon. Member for Fulham (Mr. Carrington) about Charing Cross hospital: hospitals such as St. George's are being expected to take over from hospitals that are being closed, yet they cannot provide sufficient facilities in our constituencies.

Mrs. Bottomley

The point is that health care in London uses more resources to less good effect in terms of bed usage and the number of consultants per patient than health care elsewhere in the country. All the indicators show that in London there is a great investment of resources without the same output in terms of patient care. Take, for example, varicose vein surgery. In one London teaching hospital the cost was about £1,300 compared with £210 at one hospital outside London. Resources are inappropriately used.

I made it clear that we shall go forward with the consultation on the separation of the community services from the acute services at St. George's. Time and again, acute hospitals dominate the agenda, and the community services are under-resourced and not given the autonomy and priority that they need. Many independent experts have made the same comment, and I have no doubt that the changes will lead to improved services for the hon. Gentleman's constituents.

Mr. John Bowis (Battersea)

I welcome my right hon. Friend's statement about St. George's, with its long-overdue approval for moving ahead with the application for hospital trust status. That will enable the hospital to meet the extra demand referred to it.

I also ask my right hon. Friend to do two things on behalf of my constituents. The first is to explain to Puzzled of Lavender Hill the relationship between the recommendations of the Tomlinson inquiry on transfer to the community and the improvements to waiting lists. The second is to ensure that when her ministerial colleague goes round London, and especially when he visits St. Thomas's hospital, he has in his back pocket a map of London bus routes, so that he can see where patients come from and whether there are alternative bus routes to other hospitals that may be asked to take them on.

Mrs. Bottomley

I can certainly give my hon. Friend that assurance. Clearly, travel times and transport routes to hospitals are fundamental to hospital usage. That was considered by the Tomlinson inquiry and will form part of our deliberations when we consult on the proposals.

Health waiting lists in London have been substantially reduced over the past year—by about 10 per cent. —but my hon. Friend is right to say that his constituents want an ever better service. When hon. Members have time to study the report they will see that many aspects of it identify the way in which difficulties have emerged in London—for example, the different relationships with GPs, and the difficulties they often have in securing a bed; people often use admission through accident and emergency departments as a route into hospital. All sorts of inappropriate patterns have developed in London, all revolving round an inappropriate use—indeed, a misuse —of the substantial resources put into London's health service.

Mr. John Fraser (Norwood)

May we take it from the tenor of the right hon. Lady's remarks that she contemplates closing either St. Thomas's hospital or Guy's hospital? In those considerations, what part will the development value of the site, as well as the costing of London's services, play?

The right hon. Lady recently had on her desk a report on King's College hospital which showed that the conduct of its accident and emergency department was a shambles in terms both of management and of facilities. How is that hospital supposed to cope with accidents and emergencies if one of the adjoining hospitals with similar facilities is closed?

Mrs. Bottomley

I hope that the hon. Gentleman will have detected from the tenor of my remarks that I regard that as a serious matter, and as a problem which must be tackled. It has existed for generations, and now is the time to take a view on how we can improve health services for Londoners. That is exactly what I intend to convey. No decisions have been made, and no decisions will be made until my hon. Friend the Minister for Health has had the opportunity to visit the institutions involved, and we have had the opportunity to examine the report, the costings and the resources, and to think carefully of how decisions will affect patients, what the implications are for health service staff, and what the issues are with regard to education and research. The subject is complex, but the needs of patients will come first.

I hope that the hon. Gentleman is aware that I have placed in the Library a copy of the report mentioning the accident and emergency services at King's College hospital. To King's College hospital's credit, it has already provided the service recommended by Sir Bernard Tomlinson in that it has a general practitioner available at the accident and emergency department, because A and E services in London are often used in the way in which people outside London use their GPs.

Mr. John Wilkinson (Ruislip-Northwood)

I thank my right hon. Friend for coming to the House on a day when there is the maximum number of London Members present. It is good that she should seek to share the benefits of Sir Bernard Tomlinson's advice with us in that way.

Am I right in my optimism that the consequences of Sir Bernard's recommendations for community hospitals, which do an outstanding job, will be that St. Vincent's hospital at Eastcote, and Northwood Pinner and district hospital in Pinner, in my constituency will have an even better future?

Thirdly, will general hospitals, such as Mount Vernon in my constituency, which takes patients across the borough boundaries from the home counties, such as Hertfordshire, have a better future, too? Demographic trends suggest that their catchment area will become more populous.

Mrs. Bottomley

Community hospitals are strongly advocated by Sir Bernard, because of the inappropriate use often made of acute hospitals and a relative lack of nursing home care in London. There are fewer district nurses in London, too. The report raises a number of issues in which, although the resources spent are way above the average elsewhere, the service delivered is not appropriate to the needs of Londoners today and tomorrow.

My hon. Friend will want me to give him an absolute assurance that his hospital stands to do nothing other than benefit from Sir Bernard's proposals, but, of course, I cannot give any hon. Member such an assurance, because it is only right to take forward the proposals by consulting on them and thinking about the detailed implications. However, I can say to hon. Members whose constituencies are outside the inner London ring that although they have traditionally sent patients to the costly inner London teaching hospitals, increasingly they want to treat them within local facilities, where treatment can be given more cost-effectively.

I suggest that those who argue that the quality of service in such outer London hospitals is not of the highest standard should have that argument out with some of the clinicians at those hospitals.

Ms. Tessa Jowell (Dulwich)

What the Secretary of State has said about the London ambulance service shows that she greatly underestimates the scale of the crisis in public confidence now besetting it. Does she agree that it is unacceptable for GPs to have to wait for many hours for ambulances for sick people? GPs see getting through to the ambulance service as an endless problem—often they have to deal with answerphones. Does the Secretary of State accept that urgent steps must be taken to restore safety levels to the London ambulance service, and that before any improvement in London's health service can be secured she must give urgent attention to the improvements needed in the ambulance service?

Mrs. Bottomley

The Tomlinson report is not about the London ambulance service, but I am happy to say that I expect to see improvements in the service which it delivers. The issues involved are complex. For example, the absentee rate in London is much higher than in other ambulance services. There has been a great investment in technology and equipment, and I have made it clear that I expect to see an improvement in the standard of service available to GPs and patients in London.

Lady Olga Maitland (Sutton and Cheam)

Does my right hon. Friend agree that the over-provision for London hospitals has been made at the expense of hospitals in the region, and that at St. Helier hospital, in my constituency, the changes proposed by the Tomlinson report will be welcomed? Does she agree that habits have now changed, and patients get the best possible care at their local hospitals, so that is where the resources should be concentrated?

Mrs. Bottomley

My hon. Friend is exactly right. In the past, many patients might have travelled from the outer London areas into London, partly because London was the centre of all the expertise and also, frankly, because from the point of view of the local health authorities, the teaching hospitals were effectively a free good.

The whole point about the health reforms is that the local districts now have to make informed decisions about where to send their patients. They will also want to take into consideration the cost effectiveness and the quality of that service. The patients concerned would rather be treated near to home than have to get on a train and go to London for the benefit of medical students or anyone else who might want to see them. There is a different pattern of health service available today. The Tomlinson report seeks to ensure that we take the decisions to ensure that in the home counties generally, as well as in London, we can have a service that is more appropriate to the needs of today and tomorrow.

Mr. Tony Banks (Newham, North-West)

It is no good the Secretary of State coming here like Florence Nightingale fresh out of charm school and expecting us to swallow this garbage that she has given us today. No one in the country trusts a word that this lying, incompetent Government say these days—

Madam Speaker

Order. I am not having those remarks. I am sure that the hon. Gentleman will withdraw them— [Interruption.] Order. I think that I am fairly capable of dealing with this matter if hon. Members will allow me to do so.

Mr. Banks

If it upsets you, Madam Speaker, I withdraw the remark of course.

It is no wonder that Bart's cannot compete, given that its services are based on tremendous skills. The Secretary of State is just creating a squalid market in the national health service. Will she give a guarantee that every penny saved from hospital closures in London will go into primary and community care?

If the Secretary of State has not made up her mind, what is the implementation group under the chairmanship of a Tory party member doing?

Mrs. Bottomley

I shall pass over the hon. Gentleman's earlier comments. On the implementation group, many hon. Members who have constituents who work in the health service know that they will be concerned about their job prospects. If there is to be redeployment from the acute side into the community side, there will need to be changes. Some of the consultants will need to think about their future. There are complex issues around the redeployment of staff.

Complex issues are also involved in ensuring that we have a proper provision of accident and emergency services. Sir Bernard in his report identifies 14 cancer services and a similar number of cardio-thoracic services. There is much duplication of specialist services, often on isolated sites. We need a review of those specialist services.

Tim Chessells and the implementation group will do much of the ground work, so that when recommendations are made in the new year, he is able to take forward the proposals. He will, for example, discuss matters with the BMA and with the Royal College of Nursing—with all those who are saying that we need to take decisions, but that we need to treat the staff and services properly.

Mr. Peter Bottomley (Eltham)

May I remind the House that in the final four years of the previous Labour Government, they proposed to close five of the six hospitals in the borough of Greenwich, so there is not much new in this? In terms of the implications for services, may I remind my right hon. Friend that within four miles of the House there are six neuroscience units? The previous system led to the proposal that more than £50 million should be spent on getting another neuroscience unit at the Brook hospital.

May I specifically ask my right hon. Friend that the implementation does not take place until it is clear from the Ministry of Defence whether there is a long-term future for the Queen Elizabeth military hospital? Thai: may have implications for the future of the Brook services and for the Greenwich district hospital services.

Mrs. Bottomley

My hon. and close Friend makes a good point. He is an extremely diligent and dutiful constituency Member whose constituents are extremely well served by his championing of their interests. 11 can ensure that at every level of my Department, the particular needs of the constituents of the hon. Member for Eltham will be properly recognised and understood.

Mr. Clive Soley (Hammersmith)

The Minister will know that it is suggested that the proposals for Queen Charlotte's and Charing Cross hospitals in my constituency and the neighbouring one will save considerable money. I want to be assured that if any money is saved, either by selling sites or as a result of other changes proposed in the report, it will not be used simply to mop up the existing deficit. If the Secretary of State uses the money for that purpose, she will not be able to stand at the Dispatch Box and say that the changing patterns, which are necessary in many respects, are being used to provide the services necessary for existing patients, for those in queues waiting for operations and for those needing community care.

Before the Secretary of State answers, may I remind her that the reason why no one trusts the Government on such issues is that when they closed the long-stay psychiatric units, the money from the sites was supposed to go into community care. It did not; it went to subsidise the Government in other areas. As a result, the changing pattern of health care in London and elsewhere has not been financed properly and that is why we are in trouble. I want a guarantee, please, that money saved will not be used to mop up the existing deficit, but will provide the new services to which the report refers.

Mrs. Bottomley

For the hon. Gentleman to question the Government's commitment to the health service is bizarre in the extreme. After all, we are the Government who have increased funding for the health service to the tune of well over 50 per cent. in real terms. We have a record of which we can be proud, unlike the Labour party. Every time we discuss funding, there is no doubt that this party can hold its head high and that the Labour party has to retreat from the statistics.

It is also the case that we need to ensure that resources are used effectively. I cannot make detailed announcements about resources at this stage. However, I accept the point made by the hon. Gentleman and by many hon. Members that to take forward the changes, we need to ensure that the patients are safeguarded. Patients' needs come first. We want a more appropriate and, frankly, more cost-effective service which meets patients' needs. As well as the needs of patients, there is also the need for education and research.

I am sure that the hon. Gentleman is aware that for some time there have been proposals to bring the Queen Charlotte's unit within the main Hammersmith hospital, although it would still keep its identity. It is part of the general movement in health care to realise that single-specialty hospitals are an area in which improvement can be gained by bringing them into the site of a hospital where all the disciplines are available.

Several Hon. Members

rose—

Madam Speaker

Order. We must now proceed with the Adjournment debate— [HON. MEMBERS: "Oh!"] I will take the House into my confidence. If questions and answers were shorter, I should be able to accommodate more hon. Members.

Mr. Harry Cohen (Leyton)

On a point of order, Madam Speaker. May I remind you of Speaker Weatherill's regular comments in the House when hon. Members were not called during an important statement such as this? He promised to take them first when there was a subsequent debate on the issue. Will you adopt the same procedure?

Madam Speaker

I do not give such hostages to fortune. However, I have a very good memory for faces. The hon. Gentleman had better leave it to me when I go back to my office to remember the faces that were here today.

Mr. Jeremy Corbyn (Islington, North)

On a point of order, Madam Speaker. I am sure that you will not forget beards either.

Madam Speaker

Or badges.

Mr. Corbyn

Or badges. Thank you. Further to the point of order raised by my hon. Friend the Member for Leyton (Mr. Cohen), will you tell us whether you have had a request from the Government for a special debate on the Tomlinson report so that those of us who were unable to ask questions today can develop our arguments in defence of London's health service?

Madam Speaker

I have not had such a request from the Government. As we heard the Secretary of State say today, we shall come back to the matter on another occasion when I hope that we shall have a full debate. As I said, I remember the friendly faces around me today.