§ Lady Olga Maitland (Sutton and Cheam)
There has been some speculation about the content of my speech, not least in certain parts of the media. I make it clear that I welcome the broad thrust of the Government's reforms. Although I believe that there have been dirty tricks; my right hon. Friend the Secretary of State for Health is blameless. Rather, I seek to blame petty-minded regional health authorities. My right hon. Friend and her able team have seen through those inadequate bodies and announced, rightly, their abolition. I leave it to other right hon. and hon. Members to interpret the Department's views on regional health authorities by that action.
I take this opportunity to place on record my unswerving support for the reforms put in place by the Government. There are many difficult decisions to be taken and I do not envy my right hon. Friend the Secretary of State her difficult task. I am confident that she will continue to see her way through some of the murky undergrowth that is part and parcel of the advisory process. I am certain that she will ultimately make the right decisions for London and the nation as a whole.
I have chosen to talk about the provision of cancer services in London, particularly south-west and west London. Many hon. Members will know that the London implementation group set up a group toreview specialist cancer services in London with the aim of achieving a more rational disposition, avoiding unwarranted duplication and providing a strong service and academic base for the future".That specialty review group reported to the Secretary of State for Health and the London implementation group in June 1993. Seven months later, we are still waiting for the outcome. While the group's aims were admirable, its recommendations were not. The reviews are only advisory, and should be seen as such. The Secretary of State can choose to dismiss some of the recommendations, as she did with the Tomlinson report.
Cancer is a disease which affects all ages, both sexes and all areas of the body. The successful treatment of this complex and diverse disease has led many hospitals around the world to specialise in treating only cancer. Such specialist hospitals include the Memorial Sloan-Kettering cancer centre in New York city and the Gustave-Roussy institute in Villejuif, France.
We in London are the luckiest people, as we have the Royal Marsden hospital, with its associated Institute of Cancer Research, which provides treatment and relief from cancer for Londoners and those who live beyond. That hospital has been given as an example of one of the most successful in patient care, research and teaching by the respected Swiss-based International Union Against Cancer. That is the most prestigious international organisation involved in the fight against cancer. Among its many responsibilities, it sets standards on how to organise the fight against cancer.
As many hon. Members will know, I am one of the Royal Marsden's most ardent and loyal supporters in this place. Almost a year ago, I spoke against the threat to the Royal Marsden when it first became apparent in the Tomlinson report. Not long after that, the Secretary of State for Health declared that she could see no convincing financial case for relocating the Royal Marsden to Charing Cross. However, despite that reprieve, the threat resurfaced 990 in the independent specialty review of cancer services in London that followed her statement. It proposes closing the Royal Marsden, Fulham road, by centring west London cancer services at Charing Cross, and incorporating the Royal Marsden, Sutton in St. George's trust hospital, Tooting. We would be fooling ourselves if we thought that that action alone could deliver the same level of services.
Each part of the Royal Marsden has a distinct specialist role in addition to the treatment of the more common cancers. The Fulham road site specialises in cancer of the head and neck, melanoma, sarcoma, chronic leukaemia, gynaecological and urological tumours. At the Sutton site, neuro-oncology, lung cancer, lymphoma, Hodgkin's disease, thyroid cancer, acute leukaemia, myeloma, testicular tumours, achildhood tumours, clinical pharmacology and gastro-intestinal are treated.
Both sites are supported by palliative medicine, psychological medicine, comprehensive diagnostic services and rehabilitation facilities. The hospital is not naturally divisible; each part complements the other. The proposal is no more acceptable now than it was when suggested in the Tomlinson report. I intend to fight it again, with, I hope, the same success.
Before discussing the reviews and their unacceptable recommendations, I shall take time to remind the House that we are talking about not merely another London hospital, but a national, or even specialist, international institution, whose importance in the worldwide battle against cancer cannot be overestimated.
I understand that almost 400 hon. Members have received representations from the hospital pointing out that a signficant number of their constituents were seen or treated by the Royal Marsden. That figure demonstrates the national importance of the institution in fighting cancer, when local district hospitals need a specialist centre of excellence for referral.
The Royal Marsden, with its associated Institute of Cancer Research, is at the forefront in pioneering research into the causes and treatment of the disease. Examples are too numerous to mention. The Royal Marsden is leading the way in its approach. Last year, it won the Queen's award for technological achievement. It was granted jointly to the Royal Marsden, the Johnson Matthey technological centre and the Institute of Cancer Research.
Only in the past two weeks, the Royal Marsden has made further strides. For example, regular doses of drugs given to sufferers of breast cancer through a round-the-clock electronic pump may reduce the need for surgery. Consultants at the hospital have just started the first large-scale trial in Britain of a new treatment using a pump about the size of a pocket tape recorder, which patients strap to their waists. Women in the trial all have large cancers, but with no evidence of spread that would normally require a mastectomy.
I have been told by Dr. Ian Smith from the Royal Marsden that they recently completed a pilot study that has encouraged them to believe that, by using a conventional anti-tumour drug administered in that way, they can significantly improve the effectiveness of treatment. Dr. Smith said that they were pleasantly surprised to find that the cancers disappeared completely in more than half the women studied. As a result, doctors were able to avoid surgery completely. In others, the size of the cancer was greatly reduced, making mastectomy unnecessary and requiring only limited surgery. 991 Another example of that sort of work is the pioneering research by Dr. Trevor Fowles and Professor Michael Baum into using the contraceptive drug Tamoxifen as an aid to lowering the risk of breast cancer. They ran a pilot study of 2,000 women with a family history of breast cancer. As a result of the encouraging figures from the original trial, it is now being extended to take in a further 15,000 healthy women who may be at risk because of their age.
The Royal Marsden believes that it may be saving 3,000 lives a year. An unexpected beneficial side effect of the drug is that it also appears to help combat heart disease. Such initiatives—and I have chosen just a couple to outline—are helping to improve the quality of life immeasurably for many of us.
It must be asked who, apart from a specialist cancer hospital with such resources, can invest in the future of women who may be healthy at the moment but who are doomed to die of breast or other cancers in 10 or 20 years. This is precisely the sort of work that my right hon. Friend the Secretary of State referred to in her White Paper "Health of the Nation", when she stressed the need to tackle cancer as much by prevention as by cure.
That sort of work can be done only in a comprehensive cancer centre where treatment and research go hand in hand, or, as they say at the Royal Marsden, from bench to bed and back to bench. Can anyone really imagine that that sort of arrangement between two specialist sister institutions can be replicated in ordinary general hospitals?
Hon. Members will be interested to know that representations from all over the world have been sent to my right hon. Friends the Secretary of State and the Prime Minister expressing alarm and dismay that the United Kingdom could possibly dismantle a hospital of such status, given its outstanding work in the prevention and treatment of cancer—demonstrating yet again with its advances in treating breast cancer that it is at the leading edge of research. That development was heralded not only by the national press, medical journals and other institutions, but throughout the world.
I could reel off a list of dozens of internationally renowned institutions that are backing the Royal Marsden. However, I shall mention just a few. For example, there is the Ontario cancer institute in Canada, the Research Institute for Microbial Diseases in Japan, and the M.D. Anderson cancer centre attached to the university of Texas. Many institutions worldwide are chasing the same money for research. However, they realise the importance of the work of the Royal Marsden, and are therefore expressing their alarm.
I come now to the reviews whose outcomes have so explicitly resurrected the threat to the Royal Marsden. It is good to know that the Secretary of State has an independent mind. When she was faced with unwelcome decisions as a result of the Tomlinson report, she took them. However, she has also been prepared to ignore the more reckless and foolhardy advice coming from bureaucrats in the national health service.
That was demonstrated by the Royal Marsden as recently as February, when my right hon. Friend the Secretary of State rejected Professor Tomlinson's recommendation to relocate the Royal Marsden and Royal 992 Brompton hospitals at a cost of £62 million. I am confident that my right hon. Friend will once again reject the same foolhardy recommendations.
The Labour party claims that those reviews are Government policy. They are not. They are reports of advice. But sometimes it is necessary to reject advice, however well intentioned it is, and follow one's instincts.
The first of the advisory reports was by the specialty review group which considered the provison of cancer services in London. That review group was required to produce its findings in a short time scale and has stated openly that the data collected presented difficulties in analysis and comparison.
I accept that, in some areas, inaccuracies may have innocently occurred due to those problems. However, the level of subjectivity, unattributable statements and misrepresentation of the information provided was not to be expected in a report of such importance.
The review group's argument against single specialty hospitals has not been substantiated, and its assertion that the Royal Marsden hospital cannot be considered as a comprehensive cancer centre is incorrect, using the review group's own criteria.
In fact, the Royal Marsden is the only hospital in London that is closest to meeting the review group's own criteria for the provision of cancer services. Why has no one questioned that contradiction within the report?
The report states that the bulk of the work at the Royal Marsden hospital is undertaken at Sutton, implying that the Fulham road site is underused and therefore dispensable. In fact, patient numbers are split 50:50. Both are integral to the comprehensive cancer service provided by the Royal Marsden hospital.
In considering the future of the Royal Marsden hospital, the review group looked at a number of options, but did not adequately or fairly explore the Royal Marsden's plans for the Chelsea health sciences scheme, which the London implementation group was given the task of examining by the Secretary of State in "Making London Better".
That idea has been expanded by Marmaduke Hussey and Sir Kenneth Stow, chairman of the Royal Marsden hospital and Institute of Cancer Research respectively, who have outlined their plan to make west London's medicine outstanding in every respect. Sir Ronald Oxburgh, the rector of Imperial College, has described the idea as aonce in a lifetime opportunity to create a grouping of medical capabilities and talent that could challenge any in the world in quality and size.
I question whether the benefits that currently exist in the relationship between the Royal Marsden, Sutton, St. George's and other hospitals would be enhanced or improved by the hospital merging with St. George's. That would more likely result in the interests of the Sutton site being lost within the priorities of the numerous services located within a large acute hospital.
It would make sense and be more beneficial if current supporting specialist links were maintained and, where possible, enhanced. The Royal Marsden should assume responsibility for the provision of cancer services at St. George's hospital on a contractual basis, as it already provides all of that hospital's radiotherapy. The identified benefits of merging the Royal Marsden, Sutton and St. George's in comparison with existing arrangements are grossly exaggerated and, more than that, unnecessarily expensive. 993 A further review called for by the Government looked into research carried out by the special health authorities, of which the Royal Marsden is one. Can it be coincidental that it shared common members with the specialty review and proceeded to come out with similarly damaging conclusions for the Royal Marsden? It was conducted by an expert advisory group the membership of which, in theory, should have been peer led. In fact, few members had knowledge of cancer and, even then, only in limited fields.
None of the review group had experience in managing research and development in a large organisation. However, at least three of the members were direct competitors with the Royal Marsden and the Institute of Cancer Research for research funds of their own. The Royal Marsden was also criticised in the report for being "inward looking and isolated" in the appointment of a joint director of clinical research.
Let me put the record straight. The appointment was intended from the outset to be external. Indeed, the search was conducted on a global basis. However, the indecision over the Tomlinson report blighted the post for external candidates. Professor Baum, who came to the Institute of Cancer Research in 1990 via a chair at King's, was appointed instead. Other outside candidates were considered. Even one member of the expert advisory group was approached for the post.
The search committee included two external professors, the scientific director of the Cancer Research Campaign, the second secretary of the Medical Research Council and the director of research and development at the Department of Health, Mr. Michael Peckham. That is hardly the action of an "isolated" institute, as the review team must have known.
As part of the review, international referees were approached and asked for their opinion of the Royal Marsden. Those international experts gave the hospital an outstanding rating. However, the members of the review group, none of whom were national experts, let alone international experts, took it upon themselves to ignore that advice and to downgrade it. Who on earth did they think they were? I find it surprising and irregular. One could go on to describe it as morally unjustifiable.
The whole report flies in the face of other independent reviews carried out. For example, the national research assessment exercise carried out on behalf of the Department for Education looked at 150 academic institutions. The institutions were graded on a scale of nought to five. Oxford university came first with a score of 4.8. The Royal Marsden hospital, with the Institute of Cancer Research, was graded sixth with a score of 4.4. Charing Cross hospital was graded 53rd with a score of just under 3.
Graham Hart, the permanent secretary at the Department of Health, has privately disowned parts of the expert advisory group research review on the Institute of Cancer Research which are of an adverse nature. Why, one must ask, has there been such a sustained attack on what most of us would agree is one of the finest cancer hospitals in the world and a hospital which I suggest should never have been part of the debate on acute services and overbedding in London? Let me tell the House the answer.
Many hon. Members will have driven down the Fulham road and seen as they passed the magnificent Chelsea and Westminster hospital. Its 665 beds are built around a naturally ventilated and glass-roofed atrium the size of 994 Wembley stadium with a mall and eight courtyards. Trees and works of art were brought in and plays are staged on a raised platform. The view of the atrium opens up immediately from the hotel-like reception. Escalators run to the main reception and an out-patients area on the first floor. From there, banks of lifts take people to the upper floors. It is an estate agent's dream.
The cost of this luxury is a record £202 million. The cost of beds averages out at nearly £250,000 each. Meanwhile, only two miles down the road, sits the Charing Cross hospital, which is only 20 years old.
Due to an act of bureaucratic vanity, not to mention bad planning, an unnecessary hospital was built at vast cost and in an area that already has sufficient hospital provision. If there had not been, there would be no problems now with the health authority casting around for a hospital to close.
After being severely castigated by the Public Accounts Committee last year for the massive planning blunder in allowing the Chelsea and Westminster to be built, North West Thames regional health authority has been determined to fabricate a role for the now redundant Charing Cross hospital to save its embarrassment. A health authority spokesman said:We don't deny that our capital programme has been entirely eaten up by the Chelsea and Westminster during the past five years and will be again next year.This is the same health authority which diverted money from literally hundreds of other health projects up and down the country to fill the black financial hole that is the Chelsea and Westminster on the Fulham road.
I am sure that many hon. Members will join me in congratulating the Secretary of State for Health on abolishing such wasteful health authorities, but should they be allowed to inflict such damage in their dying gasps?
I believe that much of the activity threatening the Royal Marsden has been orchestrated by the regional health authority. For example, I received a document on the future of Charing Cross hospital which included a one-page summary of key points that it wanted to convey. The document made remarks about the Royal Marsden that were factually incorrect and, as they could easily have been checked, could be subject to legal action.
I find it offensive that staff at Royal Marsden have been subjected to such indefensible slurs on their professional representations. Doctors and nurses at the Royal Marsden have spent many hours—some have spent their entire working lives—in combating cancer. For another hospital to stoop to this level shows no morals.
Several points are made that I find particularly objectionable, such as that Charing Crosshas a high reputation for serving the needs of decent everyday folk in West and Central London. We are not a hospital for the well-to-do. We have a few private patients compared to, say, the Royal Marsden Hospital where over 50 per cent. of the patients are private.That is wrong. Only 10 per cent. of the Royal Marsden's patients are private.
The document continues:Charing Cross Hospital is one of Britain's newest hospitals… Unlike the decaying 19th century or older hospital buildings you see in London.The Royal Marsden has recently begun £25 million-worth of redevelopment, in particular a new clinical block at Chelsea and a purpose-built paediatric unit in Sutton. By North West Thames regional health authority's own admission, it will require £20 million of maintenance to bring Charing Cross up to an acceptable standard. 995 The one-page summary goes on:Charing Cross Hospital has a formidable international track record in providing specialist care in cancer… Single specialty hospitals are not equipped to deal with the numerous complications which may arise from cancer—e.g., renal failure, respiratory failure and neurological difficulties.Unfortunately, Charing Cross does not havea formidable international track record",compared to the Royal Marsden, as witnessed by its poor rating in the recent University Funding Council research assessment exercise.
Cancer as a disease is not organ-specific. The hospital therefore has a large number of specialties on site. In addition, it has links with a wide range of other specialties through its honorary consultants. The summary continues:£10 million is spent on cancer research every year by the Charing Cross Hospital.The Royal Marsden, with its associated Institute of Cancer Research, spends more than treble this amount.
The report continues:Charing Cross Hospital houses the biggest cancer unit in the South East of England".That is factually incorrect and, in my opinion, a ludicrous statement. I think that you, Mr. Deputy Speaker, will understand my sadness and, unfortunately, my anger about the fact that the Riverside health authority, under the direction of the North West Thames regional health authority, has been allowed to put out such untruths.
What is my solution to the over-provision of services in west London? While not wishing to be drawn into a debate about whether Hammersmith hospital should move to Charing Cross hospital, or vice versa, I propose that Charing Cross's acute services should be located at the Chelsea and Westminster hospital to help to fill it, and that the provision of cancer services at Charing Cross and Hammersith hospitals should be moved to the Royal Marsden, which could then expand at marginal cost—estimated to be less than £1 million—to take on the extra patients.
That must be the least contentious solution; it would not only save the Royal Marsden but go some way to solving the problems facing the Chelsea and Westminster hospital. In effect, the Royal Marsden, with its institute, would continue to be dedicated to fighting cancer in its many forms at Chelsea and Sutton.
The Royal Marsden is not only held in the highest esteem here and abroad but is a much-loved institution. Many former patients have told me that, during the first terrifying days when their cancer was diagnosed, the very name "Royal Marsden" was a huge comfort to them. Dare I suggest that the name "Charing Cross", or even "Hammersmith", scarcely has the same resonance?
Time and again, the public have demonstrated their love for the Royal Marsden. Indeed, sometimes it has been impossible to hold them back. We have all been deluged with letters, some of which give very personal accounts. Let me put it on record, however, that I have received assurances from the chairman and the chief executive of the Royal Marsden that letter-writing campaigns by children or other groups of patients to hon. Members have in no way been orchestrated by the management of the hospital. They have been entirely spontaneous.
I was privileged recently to hand to the Prime Minister the largest petition that he has ever received. It consisted of nearly 1 million signatures asking for the Royal Marsden 996 to be saved in its entirety. There have also been numerous letters from distinguished supporters here and abroad, the majority of whom are internationally renowned cancer experts.
However, I should expect the Secretary of State to base her decision not on mere emotional arguments but on a rational and cost basis. By rational, I mean facts such as those presented by Dr. Michael D'Souza and 44 of his fellow GP fundholders in south-west London. With the leave of the House, I shall read part of his letter which was published in The Daily Telegraph:We are general practitioners who are currently placing our intentions to purchase health care in 1994 for a population of about 100,000.We are used to sending patients to the Royal Marsden and wish to go on doing so for many years to come. We declare our intention to place contracts with this hospital at its present Fulham Road site for the foreseeable future. Since it is the aim of the NHS reforms that taxpayers' money should follow where general practitioners decide to send patients, it would appear that those planning to close the Marsden now can only do so in open defiance of Government policy".Dr. D'Souza eloquently sums up the arguments—that is what the reforms of the health service are all about.
Let us consider the moral issue of the £25 million of donations raised by the Royal Marsden from the public over the past two years. It has spent that, plus a further £13 million from the Government, on new, state-of-the-art facilities which have enabled the hospital to remain in the first division in the world. What will the generous donors think if their money ends up as rubble in the Fulham road?
Many hon. Members have told me that the Government do not want to close the Royal Marsden. Instead, they said, the Government wish to strengthen the hospital by consolidating its services on the Sutton site. Let me state now, as the Member of Parliament for Sutton and Cheam, that that is not the solution. The greatest strength of the Royal Marsden—and its associated institute—is its ability to work as one hospital from both Chelsea and Sutton, serving not only the population of west and south-west London but the country as a whole. Moreover, if the Chelsea site were closed, it would be impossible simply to rehouse all its facilities and patients at Sutton.
The Secretary of State has herself directed the Royal Marsden to prepare and submit an application for trust status. That has now been done. The Royal Marsden looks forward to the challenges of the internal market within the national health service, and believes that it will flourish. The Royal Marsden's confidence in its future as a successful trust hospital is based on the indicative contracts that it has with purchasing authorities nationwide, and the declared intentions of GP fundholders, who have complete faith in it.
The Government introduced the internal market into the national health service in the firm belief that market disciplines would radically overhaul the levels of efficiency within the NHS. It was also judged that the marketplace would be the best determinant of the nation's health needs. I welcome that wholeheartedly.
The Royal Marsden is asking for the opportunity to prove itself in the marketplace, in keeping with the Government's own philosophy. Surely it is the patients, as purchasers of hospital services, who should be trusted to decide which hospitals they want to use, thereby determining which hospitals will rightly survive in London and which will not. I leave the bureaucrats with one thought: who gains if the Royal Marsden is cut in half?
§ Ms Dawn Primarolo (Bristol, South)
I congratulate the hon. Member for Sutton and Cheam (Lady Olga Maitland) on initiating the debate—although I must say that I thought that it would be a more wide-ranging debate dealing with cancer services in London generally rather than simply with those offered at the Royal Marsden.
I must say that I was somewhat surprised by the hon. Lady's speech. By implication at least, she denounced the inadequacies of the internal market and its failure to protect the Royal Marsden, but she failed to recognise that the three reports on London undertaken over the past 12 months have helped to create the chaos that she described so well, and that that chaos is the result of Government policy.
The hon. Lady supports the Government's reforms—except in so far as they relate to her own hospital. I repeat that we are talking about the Government's health policy: it is simply not good enough to paint a picture in which the Secretary of State and her Ministers have no responsibility for, no idea of and no connection with the policies that they are pursuing. To try to blame it on civil servants who are responsible and accountable to those Ministers as if they had had a bad dream and decided to bring this chaos down on us is simply unacceptable.
The hon. Lady complained about and singled out Charing Cross. In doing so, she was again describing the way in which the market operates. In London, as elsewhere, the Government have been operating on the basis of a totally false premise. They promised the review of services, a planned transfer and investment in primary care. In London in particular, they have demonstrated their unique incompetence to deliver their objectives.
In describing the problems of the Royal Marsden, the hon. Lady might bear in mind the fact that they can be multiplied by 28 in London alone, where numerous hospitals are threatened with closure or mergers that they do not want. Cancer and its treatment and the importance of that treatment are, I hope, well understood by hon. Members. Cancer is the second major cause of death: one death in four is the result of it. In the age group 45 to 54, half of all female deaths are from cancer.
The Government undertook a review of facilities in London. Central London has 11 specialist cancer units, but it would be invidious to pick any one as a centre of excellence. The Royal Marsden has been mentioned, but equally, Bart's could have been mentioned, and its fate is currently unknown. The review was based on information about the number of expected cases, and the review groups made specific proposals about the north-east, south-east, south-west and west, and made recommendations about the Royal Marsden. As we have heard, there has been a massive campaign to try to protect the Royal Marsden and other hospitals from the ravages of that review.
What qualifications or abilities have the Government demonstrated to show that they understand the services that London or the rest of the country need? The answer may be found in parliamentary questions, and I shall quote from a few to show the Government's lack of understanding and knowledge.
I asked the Secretary of State for Health about the percentage of patients diagnosed as having cancer who see a cancer specialist. It is important that people have access to such services, and it is particularly important for the 998 Government to plan those services, although we dispute their claim that they do. I was told that the information was not held centrally.
I asked what assessment had been made of the correlation between the degree of specialisation of consultants and the levels of morbidity and mortality among their patients. The Government confirmed, even though they do not know, the number of patients who see cancer specialists. They said that the likelihood of survival is greater if people see a specialist in the discipline. We asked about the ratio of specialists to population. That ratio is among the lowest in Europe. The Government know that people should see specialists and that we have the lowest number of specialists in Europe, but they do not know whether patients see them.
We asked about the waiting times for mastectomy in the past five years, and were told that the information was not held centrally. They do not know how many specialists there are and whether they are adequate; nor do they know whether people are seeing specialists or whether target waiting times are being satisfied. That is in spite of the fact that they issue guidance and know that, even after clinical diagnosis, women have to wait from three weeks to three months for treatment.
We decided to test the Government further, and asked the Secretary of State to list the London teaching hospitals with professors of general practice. She told us that the information was not held centrally. We asked her to list the hospitals in London that had been closed since 1989. She told us that the information was not held centrally. We asked her to name the hospitals that had been closed in each of the past 10 years. She told us that the information was not held centrally.
Finally, we asked the right hon. Lady what her plans were for restructuring the national health service in London. She referred us to "Making London Better", and said that the resources would be available so that change took placein an orderly fashion and no proposal will be agreed unless it offers a sound basis for delivering a high quality and cost-effective service to patients."—[Official Report, 30 November 1993; Vol. 233, c. 463.]
I asked myself what the Government know about health. Do they understand that there is chaos in London, with hospitals being undermined by their policy? Do they understand that they have sacked more nurses and created more management posts than any other Government—and that in three years they have created 18,000 or more new management posts, which is more than our total number of consultants? I think that they do not.
Do the Government understand that they are now being challenged over their most basic proposal for London—investment in primary care? Doctors' leaders are contesting the Government's claim that they will bring London's primary care provision up to a national standard. You may remember, Mr. Deputy Speaker, that that is supposed to be why the chaos exists in London; the idea is that, at the end of it all, we shall have better primary care. However, having studied the FHSA development plans, doctors are saying that there are no improvements, and that drastically needed improvements will not come about next year. The general medical services committee negotiators and the Tomlinson task force doctors are considering lobbying the Minister and health managers because the situation is so bad. 999 What will the Government do about all that? There is a growing number of hospital hit lists and a soaring number of bureaucrats, with new jobs being created all the time. The British Medical Association tells us that the GP fundholder system has led to fast-tracking and queue-jumping. There is a cash crisis, with a £100 million gap between what is needed in London and what is available. That puts London's care at risk.
The flagship hospital, the Chelsea and Westminster, faces a loss of £1 million and has 112 empty beds, which the management describe as spare capacity:This is entirely consistent with our plans for the future".Presumably, when people get lost among the many facilities now offered at the hospital and start to suffer from exhaustion, they will be admitted to one of the 112 empty beds—but the people on the waiting lists will not be allowed to use them. The atmosphere among staff at that hospital is described as desperately low, because staff do not know what their future will be.
What about staff in the other hospitals? How do they know what their future will be? How are people in London to believe that the Government understand the cancer services we need, and have based their plans on proper information? The Marsden and the Institute of Cancer Research are excellent clinical and academic institutions, yet the Government are inflicting random damage on them by letting loose an internal market.
Earlier this week, a Government spokesperson admitted the chaos and problems being caused. Lady Cumberblatch said:I recognise that it is impossible to avoid a period of uncertainty, which affects staff morale and the Government is committed to bring that uncertainty to an end as soon as possible".That is not in sight. We have no information about when the plans will be introduced.
The Minister must tell us what the future will be for the 29 hospitals blighted in London. What is the future of cancer services? When will the additional resources for primary care be made available? When will the Government make up their mind on the three reviews? When can we expect the establishment of a health authority for London that plans London's health needs? How do the Government expect strategic planning of a health service to be undertaken while the internal market operates and destroys that planning?
Until the Government can address those questions, we can only see a future in which our centres of excellence continue to be undermined. People will receive cheap treatment, but it will not be the best treatment.
§ The Parliamentary Under-Secretary of State for Health (Mr. John Bowis)
I am grateful to the hon. Member for Bristol, South (Ms. Primarolo) for her contribution. You may have thought, Mr. Deputy Speaker, that dawn was breaking early, but, alas, it was a mirage. The hon. Lady referred to Lady Cumberblatch and thus managed to combine the names of two of my noble Friends in an interesting way.
I am grateful to my hon. Friend the Member for Sutton and Cheam (Lady Olga Maitland) for initiating the debate. Her constituency includes one of the Royal Marsden sites, so she is well versed in the issues surrounding the future of 1000 that hospital. That is why, to answer the point raised by the hon. Member for Bristol, South, my hon. Friend dwelt on that hospital.
My hon. Friend had an Adjournment debate on the same subject earlier this year, to which my hon. Friend the Minister for Health responded. My hon. Friend is aware that the NHS trust status application for the Royal Marsden is out for consultation until next month and she will be aware that I can say nothing which might pre-empt or prejudice that consultation or the decision of my right hon. Friend the Secretary of State which will follow.
The hon. Member for Bristol, South referred to planning blight. The Government recognise the difficulties that uncertainty about the future of health services in London can cause, but my hon. Friend the Member for Sutton and Cheam will appreciate that such decisions cannot and should not be rushed: they must be right.
The Royal Marsden hospital is one of the eight London postgraduate teaching special health authorities. Its prime role, in partnership with the Institute of Cancer Research, is research and development—ranging from basic science to clinical research and health services, dissemination of good practice to the wider health service, and postgraduate and post-basic teaching and training of doctors, nurses and others. In recognition of that special role, and unlike other provider units, the hospital has for some years been managed and funded directly by the NHS Management Executive.
Before any decision is made on the Royal Marsden, the report of Professor Tomlinson, and the Government's response in "Making London Better", the recommendations of the cancer specialty review, Sir Michael Thompson's review of research at the SHAs, the decisions on the future funding of the special health authorities and the decision of the Royal Marsden to apply for trust status will all be taken into account.
I do not wish to repeat in detail the analysis that the Tomlinson report contained. Suffice it to say that although he recommended that the Royal Marsden's services on the Chelsea site should form the basis of an integrated and rationalised west London cancer service at the Charing Cross site, as my right hon. Friend the Secretary of State said to the House earlier in the year:On the basis of the information before me, I have decided that there is no financial case for relocating… the Royal Marsden hospitals to the Charing Cross hospital."—[Official Report, 16 February 1993; Vol. 219, c. 135.]My hon. Friend noted and paid tribute to that decision.
The Government responded in February with the publication of "Making London Better". That set out a clear framework for change. It was not the purpose of that report to lay down a blueprint for the future. We therefore established a special implementation group under the chairmanship of Sir Tim Chessels, to carry forward a structured programme of change and, as part of that change, to consult widely, openly and genuinely. The group will advise the Secretaries of State for Health and for Education on the implentation of decisions on the future development of health services in London and on the implications for medical education and research, will secure agreement among interest parties and oversee implementation of the changes.
§ Ms Primarolo
While the Minister is explaining the review procedure, will he tell us what steps the Government will take to protect all the hospitals while the reviews are being undertaken and there is all the 1001 speculation about their future, so that any decisions that might be taken by the Secretary of State are not pre-empted by an internal market that has already forced the hospital into reduction or closure?
§ Mr. Bowis
If the hon. Lady will listen and wait, we shall come through the procedures. I have already said that nothing that I say tonight must prejudice or pre-empt anything where decisions are being taken now, or are to be delivered shortly.
A key element informing the moves towards a more streamlined hospital service is the recommendations of the six speciality reviews that were set up on the recommendation of the Tomlinson report. The specialty review reports were published in June this year and are the latest in a long line of reports to highlight the problems of duplication of specialist services in London. That duplication works against patient care and can lead to undersized units possessing resources that are not fully used.
The aim of the reviews was to recommend a more rational disposition of services in six specialties—cancer, cardiac, neurosciences, plastics and burns, renal, and children's specialist services. The primary concerns were quality of care, value for money and ensuring that London remains a centre of clinical, teaching and research excellence. The review believed that change was needed and that excellence in service, research and educational terms was more likely to be sustained in larger multi-specialty units with strong multi-faculty links. The outcome of the SHA research review also needs to be considered.
The review teams were independent, and led by eminent clinicians from the specialties concerned. Their membership included London purchasers, GPs, nurses and patient representatives. The recommendations were made following an extensive programme of visits to the hospitals that might be affected by change and took into account previous studies and written submissions from a wide range of sources. The specialty review teams each developed a specification for a specialist centre, on the basis of which they evaluated current service provision and made recommendations for the future pattern of services. Their assessments took into account available information on the scope and scale of the specialty, appropriate models of care, criteria for a tertiary centre—including size, staffing levels, facilities and links with other services—academic links and performance—including undergraduate and postgraduate teaching and research—the quality of service and convenience for patients, and the financial viability and comparative costs of hospital sites. The two main themes that emerge from the reviews' recommendations are first, London's tertiary services need rationalising to sustain excellence in service, teaching and research and to deliver good value for money and, secondly, the large number of relatively small tertiary centres in London are increasingly constrained by their small size.
It is important to remember that the specialty review reports are advice to Ministers and the service. They will help to inform decisions about the future pattern of services in London and will be considered alongside the site option appraisals. The review of research in the special health authorities, which was published in July as strategy, is 1002 being developed by purchasers of local services. The last element is particularly important if services are to be genuinely targeted at patients' needs.
The London implementation group, which is part of the NHS Management Executive, has collated responses to the specialty reviews from the Thames RHAs, London purchasers and the hospitals affected. Those responses will also be important in informing decisions about the future configuration of hospital services, including those provided by the Royal Marsden.
The cancer specialty review was independent advice to the Government, and also to the NHS more generally. I assure my hon. Friend that it is not policy, nor was ever intended to be, and will not on its own shape the future of the Royal Marsden hospital. I can further assure her that no proposals to change cancer services in London will be agreed unless they offer a sound basis for delivering high-quality, cost-effective services to patients.
To show how seriously the Government take issues involving research and teaching, we commissioned a comprehensive review of the special health authorities' research programmes. The Royal Marsden, in line with the other special health authorities, provided evidence to an independent review group of both national and international experts set up by Professor Peckham, the NHS Management Executive's director of research and development. That distinguished review committee, led by Sir Michael Thompson, vice-chancellor of Birmingham university, reported in the summer.
My hon. Friend referred to the expert advisory group that considered the quality of research at the Royal Marsden. The group reported in confidence to Sir Michael Thompson's review committee and a copy of the report was given—also in confidence—to the chairman of the Royal Marsden special health authority. Any subsequent correspondence with the SHA was also in confidence, and it would be quite wrong for me—and not in the best interests of the hospital—to refer to the contents of that report, or indeed such correspondence, today.
In the light of the committee's report, my right hon. Friend the Secretary of State has approved substantial central support to protect high-quality research. By 1997, nearly two thirds of SHA funding will be provided centrally, under contracts that will offer considerable protection to these hospitals as they join the internal market from next April.
It has been Government policy for some time that the special health authorities should join the NHS internal market in April 1994 and that they should apply to become trusts—subject, of course, to public consultation and the normal assessment process. The Royal Marsden's trust application is currently out to public consultation, which ends on 3 January 1994. My right hon. Friend the Secretary of State should then be in a position to consider making a decision on whether to allow the hospital to proceed to trust status.
I am conscious that the Royal Marsden has been generously supported by many charitable sources. As a result, it has been able to invest millions of pounds in new equipment and bricks and mortar, which could not have taken place without this special commitment to the hospital. We certainly do not intend to put that generosity and good will at risk. Therefore, I can assure my hon. Friend that if any major change were proposed, there would be discussion with the charitable donors who have recently contributed large amounts to the hospital. The aim 1003 would be to reach agreement on reusing donated assets elsewhere to the very best advantage. That assurance would, of course, apply not only to the Marsden but to any other hospital faced with a programme of major change.
§ Ms Primarolo
How would resources in one hospital be moved to another, and who would pay for the relocation?
§ Mr. Bowis
We are not talking about specific proposals to move anything anywhere; we are talking about discussing with the donors the results of their past donations and whether some of those resources could be moved and reused elsewhere—or perhaps used in a different way in their present location That is a matter for discussion with the donors and, whether it is the Royal Marsden or any other hospital, that is what we would expect to do.
The Government value tradition and recognise the respect and affection in which the Royal Marsden is held both nationally and internationally. However, it is not sufficient to rest on past glories. We are determined to maintain and reinforce the best research and teaching of postgraduate students in all disciplines.
Much of the NHS work in the special health authority meets specific patient needs and can be funded in part through the internal market with support for the extra service costs of research and teaching. I can assure my hon. Friend that we shall exercise the greatest care in ensuring that the decisions that we make on the future of the hospital and of cancer services generally will reinforce the best research in those centres while allowing high-quality institutions outside London to benefit from NHS support for research.
The Government are concerned to ensure the provision of a consistently high standard of care and treatment for cancer patients. The Department of Health has promulgated guidance on a number of issues, including in 1984, the organisation of acute services for cancer, in 1988, the minimum viable populations for radiotherapy centres, in May 1991, quality assurance in radiotherapy and in November 1991, the treatment of ovarian cancer. It is intended to produce new guidelines on the clinical management of lung cancer in the new year.
Cancer services are funded through general allocations to health authorities. However, the Government have provided additional special funding to help develop cancer services, including £15 million in 1992–93 as the first phase of a three-year capital programme to provide linear accelerators for cancer treatment and scanners and other cancer equipment, including mammography equipment for X-ray departments. The Government have provided more than £150,000 per year for United Kingdom action in support of the Europe against cancer programme. We provided £43 million in 1993–94 for voluntary hospices, the bulk of whose patients have cancer, and supra-regional funding for four specialist cancer services to the tune of £8.6 million in 1992–93.
As my hon. Friend and the hon. Member for Bristol, South have said, cancer is a major cause of illness and premature death. One in three people will develop cancer at some time in their life. That is why the Government have made cancer prevention a priority in the health of the nation and have set targets to reduce incidence and death from four major cancers—lung, skin, breast and cervix. 1004 Prevention alone is not enough. Treatment, care and palliation are also vital in working to improve public health and to reduce morbidity and mortality relating to cancer. That is why the chief medical officer has established an advisory group of acknowledged United Kingdom cancer experts to advise him on the treatment and care of patients with cancer and on the organisation and delivery of cancer services of the highest possible quality, with the aim of improving care and treatment outcomes.
It has been argued that the United Kingdom has a smaller number of cancer specialists—oncologists—per head of population than any other country. It must be understood that many clinicians—surgeons, radiotherapists, physicians and general practitioners—have a role to play in the treatment and care of cancer. Crude comparisons of the numbers of oncologists is a misleading way of trying to estimate levels of service for cancer treatment. We are concerned to ensure that people with cancer, as with all other conditions, receive flexible and responsive treatment to meet their health needs, preferably close to home so that they have the day-to-day support of their family and friends.
The Government are encouraging health authorities to increase the numbers of consultants by 2 per cent. per year to ensure a consistently high standard of care around the country. However, in increasing consultant numbers, it is for health authorities to decide the balance between specialties in the light of demands on services.
Unlike other medical specialities, radiotherapy is devoted exclusively to cancer care. It requires a critical mass of professional and scientific equipment. The recommended minimum population for a radiotherapy centre is two thirds of a million. The Government are concerned at suggestions that patient services might suffer because of outdated radiotherapy and other specialist equipment. That is why we have made £15 million available over three years—1992–93 to 1994–95—as part of a rolling programme to help replace equipment. That concentrates largely on the provision of linear accelerators and other equipment. We encourage very high standards of quality and safety, and we promulgated guidance on quality assurance in radiotherapy in November 1991. Some equipment is old and is already being replaced, but it still gives safe and effective treatment.
Funding was provided from this programme for hospitals in London in 1992–93. Linear accelerators were provided to the Charing Cross hospital and the London hospital, as well as to Mount Vernon hospital and the Royal Marsden hospital at Sutton, Surrey. Both the latter provide services for patients from London and the surrounding area.
There are a number of specialist cancer centres around the country, such as the Christie hospital, Manchester as well as the Royal Marsden SHA.
There is no quantitative evidence to support the claim that people treated for commonly occurring cancers in general hospitals do badly and may die unnecessarily. Such claims only cause anxiety to patients and relatives. The claim that patients do better in specialist cancer centres is also unquantified, except for comparatively rare conditions such as certain bone tumours, retinoblastoma, large eye tumours, and children's cancers. Where the need for specialist centres is established, the Government have provided additional funding. Concentrating all cancer treatment in specialist centres would require patients to travel further than they do now for regular treatment. There 1005 is a clear need to evaluate the relative effectiveness and outcomes of treatment and care in specialist units and in district general hospitals, to evaluate the most effective pattern of cancer services for patients and the public health. Any assessment of outcome should consider not only the length of survival but quality of life. These are highly complex issues. That is why the chief medical officer has asked a group of cancer experts to look at this, as I said earlier. We await that advice with interest.
§ Ms Primarolo
I was told in a written answer:Confidential audit work supported by the Department of Health, and international studies, indicate that consultants with specialist skills and experience achieve better outcomes".— [Official Report, 29 November 1993; Vol. 233, c. 302.]Why do the Government give such a written answer when the Minister has just told the House that there was no proof? Can the Minister explain that?
§ Mr. Bowis
The hon. Lady is talking about people and I was talking about centres.
The key to successful treatment for many cancers is early detection. That is why we have put so much effort into cancer prevention and education to improve awareness of cancer and early symptoms and to encourage people to come forward for treatment. Cancer is a key area in the "Health of the Nation" and we have set firm targets for four cancers. The United Kingdom firmly supports the Europe against cancer programme and we lead Europe in having established national screening programmes for breast and cervical cancer.
The NHS breast and cervical screening programmes are very successful. Uptake of screening in London may be lower than the national average, but this pattern is mirrored in other large inner-city areas such as Birmingham, and reflects to a large extent the problems of providing primary care services in areas with a substantial number of homeless or transient people and an ethnic minority community for whom English is not a first language.
To answer the hon. Lady's point, that is why we are spending an additional £40 million on primary care in inner London health districts and a further £7 million on voluntary sector initiatives. I hope that she will join me in welcoming the moves already in the graph on cancer in the first full year of "Health of the Nation", where we see a 1.2 per cent. reduction in lung cancer deaths for women under the age of 75, a 3 per cent. reduction for men under the age of 75, and a 2.7 per cent. reduction in deaths from breast cancer. Those are steps in the right direction towards the targets that we have set.
The hon. Lady also mentioned statistics, and cancer registration data are vital to monitor trends in the incidence of cancer over the years. As she knows, the data are collected regionally and consolidated nationally by the Office of Population Censuses and Surveys. There have been criticisms in recent years that data are incomplete and sometimes out of date, which is why the Department of Health set up a review of improvements recommended to the national cancer registration system to enable better monitoring of the effectiveness of measures to combat cancer. The OPCS has made real progress in improving computerisation of the national system and a senior doctor in the Department of Health chairs a steering group to oversee improvements, which includes representatives from registries and the relevant professional bodies. The outcome will be more accurate data provided more speedily.
1006 Research is the lifeblood of the NHS. London is at the leading edge and we have taken positive steps to ensure that it remains so. In the 1992–93 financial year, the Department spent approximately £1.4 million on cancer research through its health and personal social services centrally commissioned programme. That includes research undertaken in London, such as that of the cancer screening evaluation unit, clinical operational research unit, and social medicine and health services research into cervical and breast cancer.
The Thompson report identified special health authority research of high scientific quality and importance to the NHS generally. Right hon. and hon. Members in all parts of the House will be delighted, as I am, that the work of some research teams was rated among the best in the same field internationally or in the lead nationally. Following the research review, we announced substantial central support over the next three years to protect high-quality research and development in SHAs.
The second recent initiative was the creation last month of a research and development task force under the chairmanship of Professor Anthony Culyer, pro-vice chancellor of York university, to review the ways in which the NHS currently funds its own research and development and supports that funded by others. Its findings are expected next spring. That is another demonstration of our determination to preserve and to extend our enviable record in health research.
An advisory group under the NHS research and development programme was formed to review areas of need relating to cancer. It will make recommendations about priorities to the director of research and development next summer, focusing primarily on the needs of the NHS. That guidance will be particularly important to providers of research that the NHS needs, and that must include all research teams in London.
In a broader sense, London plays a particular and important role in the national research and development programme for cancer that fully involves NHS research and development, major charities and also many smaller ones, the Medical Research Council, SHAs and London university.
If London is to be best equipped to undertake world-beating cancer research in future, a great number of factors must be considered. For example, advice on the future organisation of cancer research suggests that basic research will become more complex and rely more on expensive equipment and specialised technical staff. We were advised by the specialty review that much of that research is likely to involve techniques beyond the cancer field and that there is growing importance in postgraduate training of a multidisciplinary—that is, integrated care—approach to cancer care. We know, too, that clinical research is heavily dependent on a sufficiently high throughput of patients.
We must build on the current strengths of London's research institutions, developing existing links and collaborative working. To take one example from the cancer specialty review report, cancer research at Middlesex and University College hospitals in association with University college is highly regarded nationally. It is substantial in volume and wide ranging—from basic science and molecular medicine to clinical research and development. Strong research activity is found in surgical, clinical and medical oncology. Recent research investment in that respect totals £16 million. 1007 London's influence on research nationally is immense. We are determined to strengthen the capital's international reputation for medical research, including cancer research.