HC Deb 16 February 1993 vol 219 cc133-52 3.30 pm
The Secretary of State for Health (Mrs. Virginia Bottomley)

With permission, Madam Speaker, I should like to make a statement about our proposals for improving the national health service in London. [Interruption.]

Madam Speaker

Order. Hon. Members who are leaving the Chamber should do so quietly and quickly. We are about to hear an important statement.

Mrs. Bottomley

I begin by expressing my sincere thanks to Sir Bernard Tomlinson, whose report has been instrumental in carrying the debate forward.

Following the publication of the Tomlinson report, we undertook an extensive period of informal consultation with the institutions and professional groups involved. I pay warm tribute to my hon. Friend the Minister for Health for the thorough way in which he held those discussions.

London and the rest of the country are poorly served by the present pattern of health services in the capital. Despite the fact that we spend some 20 per cent. more per head in London than elsewhere, services are often ill matched to the day-to-day needs of those who live and work there. London has 43 major acute hospitals, twice as many consultants per head as elsewhere, and, for example, 14 centres of specialist cardiac services and 13 in neurosurgery.

Despite the panoply of provision, patients use accident and emergency departments rather than going to a GP; patients cannot be discharged from hospital because there are inadequate services outside hospital to care for them; primary health care services in the rest of the country are often well ahead of the care that is available inside London. This is an unacceptable imbalance. It has to be redressed. The issues are well known. They are well documented and well understood. They have been the subject of at least 20 reports in the last 100 years. For a variety of reasons, successive Governments have declined to grasp the nettle. Today we are making a decisive break with that tradition.

Patients from outside London prefer to be treated locally. This process will accelerate, and not decline, in the future. Modern medicine means also that we can treat more patients with fewer beds. Many more services can be provided outside hospital, as the pioneering advances of the GP fund holders have shown. London should be in the vanguard of change.

Our response is rooted in the principles of our health service reforms. We start from the unshakeable belief that in London, as elsewhere, it is the patient who must come first. How and where services are provided should be determined first and foremost by what suits patients.

To provide a patient-focused, modern health service in London requires a radical programme of change. The work will be carried forward by the London implementation group, reporting to me and working with the existing health agencies in the capital. It will start now, work quickly and keep to a strict timetable.

The first step must be a substantial improvement in primary care in London. That means the development of higher quality, more accessible health services at local level —provided through GPs, nurses and other professionals in the community.

I am today establishing a London initiative zone covering the most deprived parts of the city where services can be most improved. I will be providing £170 million of capital investment over the next six years for improvements in the LIZ area. Much of that money will be used to provide new and improved premises for GPs and their teams where needed, and to provide new primary care centres.

Next year alone, we will invest over £40 million additional funds in primary and community health services. In addition, a further £10 million will be specifically targeted to ease waiting time problems for inner London residents.

We will strengthen the training of family doctors, nurses and other professional staff. We will bring experienced GPs into the capital, perhaps on short-term appointments.

We will be looking at new ways of providing services —by employing some GPs directly, by reviewing relevant aspects of the GP contract, such as the system of deprivation payments, by developing the GP fund holding initiative in London, which has brought so many benefits to patients elsewhere, and by much else besides.

We expect the social services to play their full part in ensuring effective integration of local health and social services. They must make use of the opportunities provided by our community care reforms and the significantly increased resources available through the special transitional grant.

We also want to make the best use of the special skills and talents of the voluntary sector. I can announce today that I am making a further £7.5 million available over the next three years to build up the role and work of the voluntary organisations.

To focus minds on innovation and experiment, we will provide a further £1 million to initiate a London primary health care challenge fund. We look to others also to contribute to the fund. It will make money available, on a competitive bidding basis, to fund experimental schemes, especially those which aim to bring local and hospital care together and those involving the voluntary, independent or social services sectors.

Putting those ideas into place involves a shift from care in acute hospitals to primary care. This, in turn, means building up services outside hospital, with fewer hospital beds and fewer sites where acute hospital care is delivered.

We need to reduce the excessive duplication of specialist services. I am announcing today six simultaneous reviews of those services to help us determine where best to concentrate specialist services to provide high quality cost-effective care. Each review will be taken forward urgently under the joint leadership of a distinguished clinician and a senior NHS manager of a purchasing authority. They will report by the end of May.

Accident and emergency services will mainly be provided from fully-equipped departments which have good access to back-up specialist services. In addition, we envisage an increasingly important role for minor injuries clinics.

But there is also a case for some rationalisation of accident and emergency services. In particular, the regions are setting in hand consultation on the closure of the A and E at Charing Cross when the new Chelsea-Westminster is available, and on the closure of full-scale A and E at St. Bartholomew's.

We are determined that the London ambulance service should continue to make progress, to deliver a much-improved service for the considerable sums of money invested in it.

The new Chelsea-Westminster hospital is one of the most modern and advanced hospitals in Europe. This £200 million development is further proof of the Government's commitment to the national health service in London. Its completion marks the beginning of a new and better pattern of services in this sector of London.

A great deal of work has been done, in addition to the Tomlinson report. On the basis of the information before me, I have decided that there is no financial case for relocating the Royal Brompton and Royal Marsden hospitals to the Charing Cross hospital. This decision has clear implications for the future of that hospital. I have asked that detailed proposals for its future to be drawn up by the autumn. The London implementation group will also consider where best to relocate the maternity services currently provided at Queen Charlotte's hospital.

We cannot sustain extensive overlap or duplication in this part of London. In the long run, the best way forward may be an integrated health sciences centre, based at the Royal Brompton and the Royal Marsden, their respective institutes, and the Chelsea and Westminster hospital, with links to Imperial College. We will pursue that idea with those organisations.

In south-east London, consultation is under way on the proposal to merge the management of Guy's and St. Thomas's. If a Guy's/St. Thomas's trust is established, we will ask the new trust board to bring forward proposals, within six months, for consolidating the hospital services.

We also propose that the University College and Middlesex hospitals should continue to work up a proposal for rationalisation as quickly as possible. This would be considered with other priorities and subject to statutory consultation in respect of service changes. A development considerably smaller than the current hospitals combined seems likely.

In the east of London, significant changes are needed to provide a better pattern of services for the local population. People in Hackney and the surrounding area will be best served by developing the Homerton hospital to meet their needs. To make that possible, the Homerton will be established as a separate directly managed unit, with a view to it offering its patients the benefits of trust status from April 1994. We will consider urgently the proposal to build a further phase of the Homerton.

We believe it will be in the best interests of local people if some of the acute services currently at St. Bartholomew's at Smithfield are relocated to the Homerton. The hospital at Smithfield cannot continue as it is. That fact is well recognised, not least by the management and clinicians at St. Barthlomew's. Its precise future must depend crucially on the outcome of the speciality reviews and on whether or not purchasers wish to send their patients to it. In view of this, I have decided that the Barts NHS trust should not come into operation on 1 April and the shadow trust is therefore to be dissolved.

There are, in our judgment, three options for the future of St. Bartholomew's. The first is closure of the hospital site at Smithfield, with its specialist services relocating elsewhere. The second is joint management of St. Bartholomew's and the Royal London hospital. The new management would be responsible for determining whether, in light of the demand for its services, the combined hospital can continue operating from two major acute sites. The third is retention of Smithfield as a much smaller specialist hospital.

I have set in hand an urgent appraisal of each of those options, to be concluded by the autumn. The proposal which emerges will, of course, be subject to statutory consultation. Under any of the options, the services provided at Smithfield, and the number of beds, would be substantially reduced. I propose to consult separately on whether to replace its full scale A and E department with a 12-hour weekday minor injuries clinic.

The Government will also consult on proposals for the merged management of Northwick Park and St. Mark's and, subject to a sound business case being made, the relocation of St. Mark's to Northwick Park.

On medical education, Professor Tomlinson's proposals for mergers of London's free-standing medical schools with the major colleges of the University of London have been widely supported. They are in line with the university's long-standing policy.

My right hon. Friend the Secretary of State for Education has welcomed Sir Bernard's broad conclusions on education and research. He has asked the Higher Education Funding Council for England to take them forward, working with those involved, to ensure that health and education changes march in step. The funding council will consider the issues raised in the Tomlinson report about student numbers in London.

Our proposals will have significant implications for NHS manpower in London. We will make sure that their skills are kept within the NHS, by redeployment and retraining wherever possible. I intend to establish a clearing house to help those staff who cannot find alternative employment through the normal arrangements.

The Tomlinson report made clear that the root cause of London's problems is not a lack of resources. Indeed, hon. Members from outside the capital often point to the consequences for their constituents of the fact that 20 per cent. of NHS resources are spent in London on 15 per cent. of the population.

A top priority must be to make the NHS in London more efficient and effective. At the moment, we provide bridging funding to London hospitals to help them survive the loss of income they face from the fact that money is following the patients elsewhere. That is not a sensible long-term use of funds. It is unfair to London and unfair to the rest of the country. We will tackle those inefficiencies. Over a period of time that will mean more money for better services outside London.

I have not the time to describe every proposal now. Full details are contained in a document "Making London Better", published today, copies of which are available in the Vote Office.

No change is no option. Sir Bernard Tomlinson spoke of a "spiral of decline" if we do not act now. The programme of improvement must be balanced. Rationalisation of hospital services must be paced alongside the complementary build-up of services outside hospital.

London deserves a first-class primary health care service, fit for the 21st century. London deserves a better-balanced hospital service, targeted on patient needs. London deserves the radical overhaul which, for years, many have promised but none has delivered. Under our proposals, that is what London will get.

We have accepted the need for radical change. We will deliver it. My programme offers the opportunity to cure London's ills and to make London better. I commend it to the House.

Mr. David Blunkett (Sheffield, Brightside)

I pay tribute to my colleagues, who made a series of 39 visits and met more than 2,000 people when examining Sir Bernard Tomlinson's proposals.

Opposition Members find the statement deeply disappointing. It is a damp squib, with a long fuse attached to a powder keg—a powder keg of cuts, closures and capitulation to Treasury demands for cash to pay for the Government's economic incompetence.

The statement is an admission of failure: the failure to match the challenge and opportunities for the future health care of the capital; the failure of the Government's health care changes, with their commercialisation and the internal market, which have made an existing problem into a crisis; and the Secretary of State's failure to win sufficient resources to do the job properly.

Does the Secretary of State not agree that she is a latter-day grand old Duke of York, who promises much and delivers nothing? The statement is the worst of all worlds. It allows existing hospitals to wither on the vine, but does not find the resources to put the necessary health care in place; it talks about merger and unites St. Thomas's and Guy's, under the chairmanship of an ex-Conservative Minister, with a direction to close one of those hospitals.

Will the Secretary of State confirm that this afternoon she has effectively announced the closure of St. Bartholomew's hospital? In her three proposed consultation plans, she spelt out that St. Bart's could not stay open as it is, and that it would not stay open under the plans put forward to her Minister of State. If it stays on the existing site, the accident and emergency unit will be a daytime unit only.

Will the Secretary of State confirm that in the document that she mentioned at the end of her statement she gives the game away? She says: Our proposals will have significant implications for NHS manpower in London. What does the phrase "significant implications" mean? Does not the document give the game away when it suggests that a cautionary estimate shows that 2,500 beds will close over the next five years? Who will pay for the redundancies, the manpower losses and the retraining? From where will the money come and why was that not mentioned in this afternoon's statement? Where is the Treasury—behind the scenes, determining the hand of the Secretary of State for Health?

What have we had this afternoon? Will the Secretary of State confirm that in the document to which she referred, euphemistically called "Making London Better"—the title makes me choke on my words as, far from being called "Making London Better", it should have been entitled "Making Matters Worse"—paragraph 9 states: The operation of the NHS internal market will determine the precise patterns of health care in London in the future; just as it is a major influence for good elsewhere."? Is the Secretary of State telling us the truth this afternoon or is it a fact that Charing Cross hospital, the Royal National Throat, Nose and Ear hospital and, as I have already said, Barts, will close—and with Charing Cross, the medical school will close? Will there not be a major cutback in medical training in London? Is not her announcement this afternoon a totally inadequate response to the challenge facing London's health care and the rest of the nation?

Can the Secretary of State justify coming to the House this afternoon and pronouncing that increased general practitioner fund holding will help inner London, where there are three times the number of GPs working single-handedly from lock-up practices that need an immediate injection of cash? How can she tell the House this afternoon that less than £30 million a year over six years is an adequate response to the £400 million that the four inner London family health service authorities estimate to be the minimum to bring those GP premises up to an acceptable standard?

Can the Secretary of State really say that the £1 million challenge fund announced this afternoon will compensate for the complete annihilation of the inner city programme, the removal of the city challenge scheme, and the capping and closure of community care provision that will be made necessary by the Government settlement for local government from April? How can beds be freed to allow more patients to be treated if community care is neglected and the voluntary sector has to put up with £2 million a year to take on the task that local government in London should be allowed to fulfil?

Today is indeed a bad day for London, but it is also a bad day for the rest of Britain as the statement provides no answers for the investment needed in primary health care. It provides no answers to the needs of Londoners who wish to see in place proper accident and emergency facilities to deal with daytime and nighttime needs to ensure that the challenge of which the Secretary of State spoke on 29 October can be met.

Will the Secretary of State confirm that the figures and financing spelt out in Sir Bernard Tomlinson's report have already proved to be inadequate? Although the Secretary of State has announced this afternoon that the Royal Marsden and Brompton hospitals are to have a temporary reprieve because Ernst and Young found that it would cost £62 million to close them, her ancillary document states that, over the next five years, they will be "absorbed". That is another euphemism for "closed in due course".

This afternoon's exercise is one of duplicity. It allows hospitals to wither on the vine while covering the Government's back in a crisis of unemployment in facing the difficulties over the mining industry and the diktats of the Wakeham committee, which instructed the Secretary of State to cover up the closures, cutbacks and redundancies that are predicted.

Will the Secretary of State tell us how much is being clawed back from the rest of Britain's health service to pay for cuts, closures, redundancies and redeployments? How much will be clawed back from regional health service budgets over the next few years? Will we see a repetition of what happened to the Westminster and Chelsea hospital, which eventually cost £300,000 per bed? How much will be clawed back to close health services in London rather than improving them, and to put at risk projects and health care provision in the rest of the country?

Will the Secretary of State confirm that, far from protecting the rest of Britain by closing hospitals, beds and community facilities in London, she is putting at risk projects that hon. Members on both sides of the House would like to see in their regions? Is not the document a capitulation to the Treasury rather than a health document ensuring the care of Londoners in the years to come?

Mrs. Bottomley

That was an enormously disappointing response. The hon. Member for Sheffield, Brightside (Mr. Blunkett) has himself said in the past that the status quo was no longer an option. It is no longer an option. In the past 100 years, 20 reports have been produced urging radical change, and that is what we intend to bring about.

I should be surprised if the hon. Gentleman's constituents in Sheffield did not point out to him that, if London contains 15 per cent. of the population, there is no long-term justice in its having 20 per cent. of the expenditure. The hon. Gentleman has again shown himself in his true colours, as an Opposition health spokesman sponsored by the National Union of Public Employees. Jobs are always put before patients.

We are going to see through firm action. The hon. Gentleman indulged in the traditional Labour pursuit of plucking a figure out of the air and then doubling it. Tomlinson recommended primary health care capital investment of £140 million; I have made available £170 million, as well as £10 million for the waiting list initiative and £7.5 million over three years for voluntary organisations. We are determined to see an improvement in primary care.

I have already referred to the generous funding for implementation of "Care in the Community". We must ensure that progress is made. We all recognise that some loved and respected London institutions will have to make difficult decisions; but it is not possible for 43 hospitals with 250 beds to remain unscathed at a time when, all over the home counties, new, high-quality hospitals are opening and providing excellent, cost-effective care.

We are not prepared to fudge this issue; we are not prepared to duck it. Any serious commentator, professional or politician will see the comments of the hon. Member for Brightside for what they are—a populist, knee-jerk, unreconstructed, destructive reaction.

Mrs. Marion Roe (Broxbourne)

I congratulate my right hon. Friend on her statement, and on the courage that she has displayed in grasping the nettle represented by this highly sensitive and emotive issue. As she knows, many ex-Londoners in my Hertfordshire constituency have been aggrieved for many years by the fact that too many resources have been taken by the London hospitals, while too few have gone to serve the local communities in Hertfordshire and the surrounding home county areas. How will my right hon. Friend's proposals address the problem so that I can assure my constituents that they will receive proper health care in their local areas?

Mrs. Bottomley

I can give my hon. Friend exactly that assurance. Once again, she has made an informed and authoritative contribution. Many health providers in constituencies such as hers are developing first-rate health services, and no longer wish their patients to go to London.

In the past, going to London was a free good, but an internal market means that the local health authority must pay, and pay the high prices of London. The fixed overhead costs of the London hospitals will become ever greater as health authorities in constituencies such as that of my hon. Friend the Member for Broxbourne (Mrs. Roe) make the understandable and sensible decision to treat patients locally. We estimate that, next year alone, £50 million worth of contracts will no longer go to London. We have to have managed change in London. We also need urgent change in London so that we can ensure a fairer distribution of health service resources across the country.

Ms. Liz Lynne (Rochdale)

I welcome the fact that the Secretary of State has announced that she does not intend to close hospitals wholesale. At least she has partially taken advice and intends to go out to consultation. I do not believe, however, that the £170 million to which she referred for primary health care will be enough. Will the Secretary of State make a commitment today that the £170 million will at least be ring fenced or earmarked for primary health care? Will she also make a commitment that she will not backtrack, as she did with the alcohol and drug misuse budget? Will she make a further firm commitment that before any hospitals are closed primary health care will be in place?

I welcome the fact that £10 million has been given towards cutting down waiting lists in London, but I should like to find out exactly when waiting lists in London will be cleared with that money. Nevertheless, I am grateful that that money has been provided.

Mrs. Bottomley

I thank the hon. Lady. I can give her an assurance that the £170 million for investing in primary health care in London will be used only for that purpose within the London initiative zone. I remind her that Sir Bernard Tomlinson's estimate was £140 million. We are making £170 million available.

I find the hon. Lady's comparison with the drug and alcohol ring-fenced money rather strange. Apart from the fact that we ring-fenced the drug and alcohol money, we ring-fenced the whole of the community care money—£565 million, an increase of a third over what was available through social security. That will lead to £30 million more in London next year and £130 million more for community care in London by 1996.

In the discussions on the waiting time proposals, I know that the hon. Lady made the point that more should happen about waiting times in London. The sum of £10 million will be spent in London. Good progress has already been made in the past year. The number of those waiting for more than a year in London has fallen by 61 per cent. in the past year, and the overall lists have fallen by 8 per cent.

Mr. Matthew Carrington (Fulham)

My right hon. Friend will know that the decision to close Charing Cross hospital will be met with horror in west London, where the facilities of that hospital are greatly needed in a very deprived part of the metropolis. Can my right hon. Friend explain why she has decided to pre-empt the specialty review in London by deciding to keep the Royal Brompton and the Royal Marsden hospitals independent and not to move them to the Charing Cross site, ahead of a full review of the cancer and chest specialties in London?

Mrs. Bottomley

I well understand my hon. Friend's support for his own local hospital and his concern about my statement. After studying further information during our discussions on the Tomlinson report and further appraisals that we were able to undertake, we took the view that it was not a cost-effective option to move the Royal Brompton and the Royal Marsden hospitals to the Charing Cross site. However, my hon. Friend is right: we are establishing forthwith specialty reviews. They will be chaired by a clinician from outside London in each of the six key areas. We hope that the Royal Brompton and the Royal Marsden hospitals will come together as a trust, sharing costs and seeking considerable savings. They will be subject to those specialty reviews, as will all the other specialist centres in London.

Mr. Peter Shore (Bethnal Green and Stepney)

Is the Secretary of State aware that the statement that there are too many hospital beds in London will be greeted with ribald laughter in a large part of the capital, where long waiting lists are still growing? May I ask her, since she did not, in my recollection, mention the Queen Elizabeth Hospital for Children, whether good sense has prevailed in that case and that it will be left alone to carry on serving the people in my part of London in the way that it has done in the past?

Mrs. Bottomley

I am surprised by the right hon. Gentleman's comment, since informed commentators, professionals and many politicians on all sides have recognised that there is a need to tackle the over-provision of beds in London. That over-provision can be tackled only as the primary care services develop. I should have thought that the right hon. Gentleman would agree that there was a misuse of hospital beds in London because of inadequate primary care services. In addition, the implementation of community care must be closely tied in with further steps on hospitals.

As for the Queen Elizabeth hospital in Hackney, which I have visited a number of times, it will join with the Homerton hospital to continue to provide a good quality local service. We certainly hope that the research, staff and ties of loyalty with Great Ormond Street will continue, but when the right hon. Gentleman studies the Tomlinson report, he will see that it makes a powerful argument for ensuring that single specialty hospitals are drawn in to the local community that they serve so that they can benefit from the range of skills at the local district general hospital, as with the London Chest hospital joining the London hospital.

Dame Jill Knight (Birmingham, Edgbaston)

Does my right hon. Friend recall a leader article in The Guardian last October or November which said that only a political ostrich could fail to take note of the fact that more money per head was spent from the health budget on London than on anywhere else but that it provided a worse service? Will she confirm that most of the London hospitals were set up nearly 100 years ago and that not only treatment but the use of day beds, instead of keeping people in hospital, has changed out of all recognition since the time when the London hospital scene was first established? Will she, therefore, take the opportunity to tell the political ostriches and dinosaurs on the Opposition Benches—they seem to be about half and half—the truth about the matter?

Mrs. Bottomley

I well remember that editorial in The Guardian. I also remember a similar report in Nursing Standard which said that the professional organizations which have for years been arguing for a radical shift in resources from hospitals to primary care cannot now condemn a report which is founded on that principle.

My hon. Friend is, as ever, exactly right. The provision of health care in London is based in the past. We are determined to plan for the future. Florence Nightingale said that St. Thomas's should move out to Blackheath, and 20 reports in 100 years have urged action on us. We are determined to see exactly that action.

Mr. Brian Sedgemore (Hackney, South and Shoreditch)

Why does the Secretary of State talk to the House as though she thought that St. Bartholomew's and the Homerton hospital were separate hospitals? As she is the Secretary of State for Health, she must know that it is the same institution run by the same people, with the same doctors and consultants. She proposes to destroy both hospitals. Does she not understand that her announcement has shown her to be a medically ignorant political chancer who deserves the undying contempt of us all because she is putting at risk 100,000 people in south Hackney, 100,000 in Islington and 300,000 in the City? What is the virtue in that?

Mrs. Bottomley

I am sorry to have inflamed the hon. Gentleman. I am used to reading his castigation of his own party's spokesman on the matter of health reform in London.

I have announced that we wish Homerton hospital to proceed with proposals for its phase 2 development. We envisage a central position for Homerton in serving the local population and in working with joint management with the Queen Elizabeth hospital in Hackney because we well recognise the needs of that part of London.

St. Bartholomew's will have to face the economic facts of life and the reality of health care today. It has the choice of closing, setting up as a small specialist unit or joining the London hospital. In my view, it is a choice between sentiment and excellence. It will need to consider urgently the way it wishes to proceed. I am concerned to serve local people, and the Homerton hospital is the place that will best do that.

Mr. James Couchman (Gillingham)

As perhaps the only former London health authority chairman in the House, I welcome my right hon. Friend's announcement. I have been the chairman of an outer London district and now represent a constituency beyond that. Both have been deprived of resources because of the over-resourcing of inner London. My constituents and those for whom I was responsible as a health authority chairman will welcome her statement. However, may I ask for her assurance that the resources necessary to ensure that people living in outer London and beyond can be treated in their own district general hospital will be provided from the savings made from London? Without those savings people will still be inclined to go to inner London for their treatment. Will she also ensure that, if some consultants will no longer have jobs in inner London, they will be steered to outer London and beyond for their new jobs?

Mrs. Bottomley

Once again, my hon. Friend, who has great knowledge of these matters, speaks on behalf of many others in the House. We estimate that next year contracts to the tune of £50 million will no longer come to London because many, like my hon. Friend, wish patients to be treated more cost effectively in their local communities.

We wish to ensure that, as a result of the specialty reviews, those units which find no future for themselves in London, and particularly their consultants, should certainly have the opportunity to find a productive role in the home counties and elsewhere in the country.

Ms. Mildred Gordon (Bow and Poplar)

Does the Secretary of State know that on 29 January there was a seven-hour waiting time at the accident and emergency department of the Royal London hospital, Whitechapel, two days before the accident and emergency department at Mile End was closed for good against the wishes of the population? She now proposes that the accident and emergency department at Barts should go for a burton and that its workload should also go to the Royal London hospital.

Is the Secretary of State aware that the Queen Elizabeth Hospital for Children serves children in Tower Hamlets, which has the fastest growing birth rate in the country, and that if that is merged with Homerton, those children will go to the Royal London hospital, further increasing the workload there and, presumably, the waiting time? I do not know what waiting time is considered acceptable in the document so cynically entitled "Making London Better", but the waiting time and the workload at the Royal London are becoming unacceptable.

What sense is there in destroying the marvellous work done at Great Ormond Street by taking away its research department? What sense is there in merging the London Chest hospital with the Royal London so that within five years it will be moved from its salubrious green site in Bethnal Green and rebuilt on what is a dirty, dusty and polluted site for chest patients on Whitechapel road? What nonsense is all this?

Madam Speaker

Before the Secretary of State answers, I plead with right hon. and hon. Members on the Front and Back Benches to put short questions and make speedy answers. Many hon. Members want to participate and I cannot allow questions to continue for much longer.

Mrs. Bottomley

I well understand many of the points of misinformation in the hon. Lady's question. She will be able to study the document and will in many ways be reassured when she understands the arguments behind many of the decisions.

It is appropriate for specialist hospitals to be under the organisation of a local general hospital in order to provide a broader-based health care for those in need of acute services. The hon. Lady's constituents, who may go to the Queen Elizabeth hospital with their children, will be treated at the Homerton, perhaps as a maternity or a surgical case, and we envisage the management joining the Chest hospital there. I have not announced that those hospitals will move into the buildings of the hospitals under whose management they will come.

On waiting times, the hon. Lady may not have heard me point out that in London in the past year the number of those waiting for more than a year has fallen by 61 per cent., which is a considerable achievement. The overall list has fallen by 8 per cent.

With regard to the hon. Lady's last point on pressure on accident and emergency, I have visited the accident and emergency department at the Royal London. She will be aware of the tremendous unpredictability of demands on accident and emergency services, but all are agreed that one of the dilemmas in London is the inappropriate use of accident and emergency services by people who would normally go to a GP or a community nurse. The right way forward is by developing effective alternatives that local people trust.

Sir John Wheeler (Westminster, North)

It takes great courage and conviction to do what is right in the health service for people in London, and my right hon. Friend has achieved that today. Does she agree that the most important part of these changes is the development of the primary health care service, particularly in London? Will she add further to her statement on how she sees the flow of funding and the development of that service leading to the objectives that she has outlined today?

Mrs. Bottomley

I am grateful to my right hon. Friend. It is exactly by effective and fast development of primary care that we shall achieve change. The London initiative zone offers the opportunity to pioneer and innovate and to find new ways to make sure that we have the primary care that meets the needs of Londoners.

It is well understood that London has a greater number of homeless people, of people from ethnic minorities, of people with drug addiction problems and of people not registered with GPs. GPs have difficulties on premises; there are more single-handed GPs and there are more older GPs. It is by finding new ways and new procedures for tackling those problems that we shall make progress. We shall set up a primary care forum, to be chaired by the chairman of the London implementation group, to take forward change swiftly. We anticipate spending £40 million extra on primary care services in the first year alone.

Ms. Kate Hoey (Vauxhall)

Does the Secretary of State not agree with me that it is a bit of a farce to talk about consultation on the amalgamation of trusts between St. Thomas's and Guy's when the chair has already been appointed and the whole thing has obviously been sewn up? Would she clarify what she means in her statement by saying that those two hospitals are consolidating? Does she mean that one of them will close, whatever is said, and will she say what will happen to those people who depend on the accident and emergency service at St. Thomas's if that accident and emergency service should ever close?

Mrs. Bottomley

At present there is statutory consultation under way on the proposal for Guy's and St. Thomas's to join together as an NHS trust. We are then asking them to go out to consultation on an independent appraisal on site options. Radical change has to go forward in London. This cannot be achieved without difficult decisions being made and on the basis of the independent appraisal. We shall certainly want them to follow through the recommendations of that appraisal, but it will be within their responsibilities and for their decisions as an NHS trust.

The hon. Lady well knows that within her constituency there is the development of initiatives such as the West Lambeth community care centre. She well knows that that is the right way to provide a modern health service for her constituents. It is not possible for her to seek development of initiatives such as the West Lambeth community care centre, as well as having, within a short distance, 500 hospital consultants at Guy's, St. Thomas's and King's. It is that sort of imbalance that makes hon. Members from outside London urge swift action.

Dr. Charles Goodson-Wickes (Wimbledon)

My right hon. Friend will recognise that her announcement today will be the cause of qualified rejoicing at Bart's, but I hope that, on reflection, the hon. Member for Hackney, South and Shoreditch (Mr. Sedgemore), who has been robust in his defence of Bart's, will recognise that we now have two viable alternatives to the disastrous Tomlinson recommendation to close Bart's and sell the site. May I urge my right hon. Friend to ensure that the consultation process is speedy and vigorous and, this time, is based on properly-based data?

Mrs. Bottomley

I can give my hon. Friend precisely that assurance. I think that St. Bartholomew's has now begun to face the economic realities. It will not be possible to persuade health authorities to send patients to hospitals that do not provide a cost-effective service. That is the reality of the NHS reforms that we have established. It will have to choose between whether it takes forward its ideas of becoming a small specialty hospital or decides to combine with the Royal London. There are strong arguments that, if it sees the future as being a centre of excellence, it will be by following the example of very many others and saying that it wants to pool the skills, resources and expertise of their teams. These decisions need to be taken swiftly, because we wish to avoid the spiral of decline outlined by Sir Bernard Tomlinson. The specialty reviews are to complete their work within three months, and the further proposals are to be ready within six months.

Mrs. Bridget Prentice (Lewisham, East)

The Secretary of State has said today that she is to initiate a new London primary health care challenge. She also said that she was looking to others to contribute to the fund. Is she prepared to tell us who those others might be? Are they to be the banks, or are they to be McDonald's and the other hamburger joints? Or are they to be the patients themselves? Having contributed to that fund, who is to decide the competitive basis on which the bids will be won? How many people in the local community will have a say in what happens at the local hospital?

Mrs. Bottomley

I am very surprised to hear the hon. Lady's prejudice against McDonald's. If McDonald's wishes to make a contribution to the primary care challenge fund, we shall certainly welcome it. We wish to have a great number of innovative ideas about where we can find premises. The real challenge for primary health care in London is the issue of premises. We certainly will explore the idea of family doctor premises becoming established in a wide range of places, and—who knows? —McDonald's may well be an option.

I thank the hon. Lady for her suggestion. But, of course, it is a travesty of the amount of money that I have announced: £170 million over six years for capital development; £40 million in the first year; £7.5 million for voluntary organisations; as well as the £1 million for the challenge fund.

Dame Angela Rumbold (Mitcham and Morden)

My right hon. Friend will know that I served on one of the previous investigations into the London health service, so I am more than well aware of the difficult decisions that she and her Ministers have to take in considering the London issue. I congratulate her on the very skilful way in which she has solved the problems. I believe that the answers that she has outlined to the House this afternoon will certainly provide much better services for London in the long term, and better services for hospitals outside London. I also thank her on behalf of my constituents, many of whom work in the Royal Marsden at Sutton, because they will be very relieved to understand that their jobs are secure for the time being. May I ask her, however, what she envisages for the specialty reviews? A little more clarity on those would be helpful.

Mrs. Bottomley

We shall be establishing forthwith specialty reviews in the six key areas of cancer services, cardiac services, neuro-sciences, renal services and paediatric services, to be chaired by an expert from outside London and with a manager from within London. They will report within three months. There will be further consultation on those reports afterwards.

I thank my right hon. Friend for her generous remarks. We have to see change; we have to see change to a tight timetable. At the same time, we have to go through the proper procedures of consultation. I am very appreciative of the way in which most people in the service, most commentators and most professionals have well understood the need for change. No change is no option. We need now to carry it forward.

Ms. Glenda Jackson (Hampstead and Highgate)

Is the Secretary of State aware that it will come as a surprise to my constituents to discover that London is over-funded, in the light of rising waiting lists, cancelled operations, the mentally ill wandering our streets and a constant diminution of the services for geriatrics?

Why is the right hon. Lady so concerned about saving money in the London area? The Royal Free medical school in my constituency can train a doctor for between £10,000 and £12,000 a year, as can the other London teaching hospitals, yet the universities of Oxford and Cambridge can only train for £18,000 a year. Is she perhaps not concentrating her sights in the wrong area?

Mrs. Bottomley

I am surprised that the hon. Lady for ever denigrates the achievements of the Royal Free hospital, because it is providing more high quality care to more patients. I have already informed the House that waiting lists are coming down. There is a 61 per cent. fall in the number of patients waiting for more than a year, and an 8 per cent. fall overall—

Ms. Jackson

On a point of order, Madam Speaker.

Madam Speaker

Order. I have to take points of order at the end of the statement, as the hon. Lady knows—[Interruption.] Order. An argument about policy is not a point of order for the Chair.

Mrs. Bottomley

The hon. Lady is right to say that we need to develop better services for the mentally ill who, above all, need primary care services. They need more community psychiatric nurses, so that many of the changes that we propose will be nurse-led. Nursing will be the crucial professional group. London has twice as many consultants per head of the population as outside areas. There is a distorted budget in London, focusing on inappropriate priorities. We wish to introduce changes to allow people to achieve exactly those objectives.

Sir Peter Emery (Honiton)

Does my right hon. Friend realise that the House knows that she has an extremely difficult task? Does she know that I was under surgery only last Thursday for a leg and vein operation and, due to the brilliance of a young houseman at the Charing Cross hospital, Dr. Backhouse, who spotted a growth on my chest that has since proved to be cancerous, the professor of surgery there, Mr. Greenhalgh, has removed it all so that I have been given a clean bill of health—with much relief to the Chief Whip, I am told?

Will not Charing Cross be given the opportunity, with the use of the internal market, to see whether Riverside health authority and North Thames health authority and surrounding areas can provide the necessary psychiatric and community care in west London which would then allow this immensely successful hospital to survive?

Mrs. Bottomley

I am delighted to see my right hon. Friend with us—I am probably as delighted as the Whips are—and I share his tremendous commendation of the doctors, nurses and others who work in the national health service. We in Britain can have confidence that we have a national health service available to all and, of course, we wish that to continue. However, a few people believe it is possible to provide a cost-effective service in future without addressing the problems in London. We will consider closely all the options at the Charing Cross and the region and try to plan for the future.

As my right hon. Friend rightly says, there are a number of beds for geriatric and mentally-ill patients for whom provision will have to be made. We cannot take forward our proposals by fudging every issue. We will take decisions in the interests of the national health service in London and elsewhere. I believe that all those who work in those great institutions know full well that change has to come. They wish decisions to be made and uncertainties to be brought to an end.

Ms. Diane Abbott (Hackney, North and Stoke Newington)

As one of the Members of Parliament representing Hackney, my concern throughout has been the level and quality of health care available to people living in Hackney. On behalf of those people, I must give one cheer to the announcement that stage 2 of the Homerton might be built, but I must stress how vital it is to health care in Hackney.

Will the Secretary of State say whether the £170 million being made available over six years is new money?

Finally, on redundancies, Conservative Members are quick to sneer when we talk about hospital workers, but let me remind them that thousands of hospital workers whose jobs are threatened are women, relatively low-paid workers, and often single wage earners in areas of high unemployment. Often, they are black women who came to the United Kingdom in the 1950s and 1960s and who have given their lives to the British health service. Opposition Members should give a little more respect to, and be a little more concerned about, the issue of redundancies.

Mrs. Bottomley

1 am pleased that the hon. Lady applauds the further plans for Homerton. We recognise that there is a need for further investment to serve that part of London. I am referring to the extra £170 million for primary care, apart from all the other announcements which I have made today.

I well appreciate the point which the hon. Lady makes about staff. When we first published the Tomlinson report we sent a newsletter to all staff in London. I am now sending another letter to all those who work within the service. Of course, uncertainty is difficult for them: they need to know the full facts as soon as possible.

We are setting up a clearing house to ensure that, across London, we look carefully at redeployment, retraining and the way in which we can most sensitively and helpfully handle the human resource question. Each year, there is a turnover of about 20 per cent. in nurses in London. I hope that it will be possible to keep the redundancies to a minimum.

Mr. David Mellor (Putney)

May I thank my right hon. Friend for what she said, and especially for acceding to the representations of a number of us that the Royal Brompton and the Royal Marsden should be allowed to continue their excellent work where they are? I am sure that there will be enormous relief about that.

I invite my right hon. Friend to recall that it was the London health consortium, under the last Labour Government, which first proposed that there should be a cut of 2,000 acute beds in London. Since then, the national health service has been transformed by the creation of hospitals of excellence throughout the nation. That makes this restructuring of London's health services—however painful—long overdue and necessary. I assure my right hon. Friend that she will have the support of all Conservative London Members if she proceeds as sensibly down that course as she has given evidence of doing this afternoon.

Mrs. Bottomley

I thank my right hon. Friend for so eloquently and effectively putting precisely the argument: we have to go forward with these changes. I thank him for his comments about the Royal Brompton and the Royal Marsden. We are persuaded that, together with Chelsea and Westminster and the associated institutes, there is scope for the development of a Chelsea health sciences centre. As special health authorities come into the market, we will protect the research component, but it is important that they play their full part and look for the savings and efficiencies which all other members of the health service family are exploring.

Mr. Simon Hughes (Southwark and Bermondsey)

Will the Secretary of State guarantee to the people of south-east London in general and the users of Guy's hospital in particular that, as a result of her announcement today, the time between referral to a hospital and treatment will be shorter and a bed will be available when they need it, but that the retention of health care both at Guy's and St. Thomas', as a result of her carefully worded announcement, is still an option for the trust to consider and a possibility at the end of any review period which a new trust will start in a few months' time?

Mrs. Bottomley

I can certainly guarantee that, if not as a result of the announcement immediately, certainly the development of our plans for London's health service is intended precisely to provide better health care for London and Londoners.

Often there has been a predominance of specialist services at the expense of routine local services which local people need, whether from the primary health care team or, when appropriate, the hospital. The hon. Gentleman will know that only a short distance from his constituency, at King's College hospital, 40 per cent. of the patients attending there would normally go to a GP or a nurse. We must achieve a better balance within London and across the country.

On the proposals for Guy's and St. Thomas's, it really is a matter for the trust once it is established, if I agree to it, subject to consultation. Of course, I must preserve the legal niceties when the trusts go forward for their site appraisals.

Mr. Toby Jessel (Twickenham)

Is my right hon. Friend aware that the drop in waiting lists is tremendously welcome? Surely what matters to patients is not only the number of beds but the effective use to which they are put?

Mrs. Bottomley

How right my hon. Friend is. I agree with him.

Mr. Jeremy Corbyn (Islington, North)

May I invite the Secretary of State to stop playing ducks and drakes with London and the rest of the country when boasting of good quality health care? Is she now aware that the Tomlinson report is seriously flawed in much of its analysis of the provision of beds in London and the use of accident and emergency departments because of the incidence of poverty and homelessness in London? Does she not recognise that increasingly inadequate primary care resources will probably lead to an increased demand for hospital places? Does she not think that it is necessary to halt the hospital closure programme and instead examine seriously the health needs of Londoners as a whole, including improvements in the primary and community care facilities, which receive only a small amount of money from her proposals?

Mrs. Bottomley

I do not accept what the hon. Gentleman says. I am Secretary of State for the national health service. At present there is one hospital doctor or GP to every 500 people in London. The national average is one to every 1,100. There are twice as many consultants in London. All the figures are out of balance. In my view, the Tomlinson report, following as it did the King's Fund report, in which representatives of all political parties were involved, makes a powerful case which any responsible Secretary of State would want to see taken forward.

Sir Rhodes Boyson (Brent, North)

I should like to ask my right hon. Friend the Secretary of State two questions. First, people in my constituency and throughout London are proud of the specialist hospitals in London, which are renowned not only in London but throughout Britain and the world. Is she aware of the depth of feeling about that in London? Secondly, my right hon. Friend said that 2,500 hospital beds in London would be taken away. Although I warmly welcome the £10 million to cut waiting lists, I have to battle every day to get people into hospital. Is my right hon. Friend aware that the people in London will be slightly cynical about the idea that there is a quick way into hospitals in London?

Mrs. Bottomley

My right hon. Friend is right when he says that there is great respect for the specialist hospitals. However, the issue is not necessarily the buildings but the skills of those who work there. I sometimes think that my job is supposed to be an arm of the Department of National Heritage. I do not see it in that way. There are strong cases for ensuring that specialist skills are part of a wider team with a wider range of skills, expertise and back-up facilities. That is the thrust of the Tomlinson report.

My right hon. Friend referred to the difficulty of his constituents in getting a hospital bed. That is pertinent to the lack of primary care in London and the use of accident and emergency departments where otherwise people would use a GP. It was estimated by one of the teaching hospitals that up to 15 per cent. of the beds were occupied by people who elsewhere would have been cared for in the community. Of course, we must get primary care right, but the combination of rationalisation of specialist services, contracts leaving London and the development of primary care will make such changes absolutely essential.

Rev. Martin Smyth (Belfast, South)

I understand the difficulties of the Secretary of State when she makes decisions about London, but let me put it on record that it is not a case of the rest of the nation against London. I have had representations from constituents in Northern Ireland specifically about the Royal National Throat, Nose and Ear, the Royal Marsden and St. Bartholomew's hospitals.

I should like the Secretary of State to consider another aspect. How will the students who are being trained obtain sufficient experience and hands-on treatment in the medical schools of London if we scatter the hospitals and research facilities for the nation?

Mrs. Bottomley

To start with the hon. Gentleman's final point, he is probably well aware that many of the London teaching hospitals have difficulty in putting enough cases through for the medical students to see. That is the dilemma. The rationalisation of the medical schools and the associated hospitals is given high priority by the Higher Education Funding Council. We want to see curriculum changes in undergraduate education. We need better primary care facilities in London to enable students to learn.

The first part of the hon. Gentleman's remarks is totally in line with our proposals. I understand his point about sentiment and loyalty to particular institutions. The issue is not the obliteration of units and teams; it is the appropriate location of teams in a setting where they can make a contribution, along with others with different skills and expertise. That is the way forward if we are continue to have a centre of excellence, famous not only in this country but also in the world.

Sir Anthony Grant (Cambridgeshire, South-West)

Can my right hon. Friend confirm that her policy will be to the benefit of such hospitals as Addenbrookes—a teaching hospital—and Papworth, both of which are located in the fastest-growing area of the country and are just as excellent and important as London hospitals, which are in an area of declining population?

Mrs. Bottomley

My hon. Friend has the privilege of being served by two.first-rate hospitals. It will certainly be to the benefit of everyone in the country when we no longer have to subsidise London to the extent to which it is being subsidised at the moment. We estimate that, this year, we are subsidising the London institutions to the tune of £50 million. Next year the figure is likely to be £100 million. As contracts are taken away, as patients wish to be treated outside London, the London hospitals will be left with very heavy, fixed overhead costs. Nobody is served when health resources are invested in buildings and an expensive infrastructure rather than in patients.

Ms. Dawn Primarolo (Bristol, South)

Does the Secretary of State agree that we should be discussing the report "Making London Better" rather than her statement? The report outlines clearly the fate of the London hospitals—death by a thousand cuts. The Secretary of State will not admit it to the House, but that is the Government's intention.

Does the right hon. Lady agree that it is wrong that the internal market should determine the pattern of health care in London, as well as in the rest of the country, which will suffer the same fate, as is detailed in paragraph 9 of the report? Does she agree that the Royal Brompton, the Royal Marsden, St. Bartholomew's and Charing Cross hospitals should not be left at the mercy of the market, to wither away on the vine, as is detailed in paragraph 62 of this report? Does the Secretary of State agree that special health authorities should not be exposed to the vagaries of the market and to certain destruction, as is detailed in paragraph 85 of the report?

Does the Secretary of State agree that the 20,000 health workers—nearly the same number as in the case of the miners—who will lose their jobs are not satisfied with the safeguards that she has announced to the House? Does she agree that any funding for London will be recycled money lost by London as a result of the introduction of weighted capitation? If that is not the case, where will the money come from? Will it be top-sliced from the regions? Will the Secretary of State confirm that UCH Middlesex and Great Ormond Street will remain in existence, that they will not be scaled down or eradicated? In this respect, I refer her to paragraph 66 of "Making London Better".

Does the Secretary of State accept that she has done nothing to arrest the decline of the health service in London and that her proposals on community care are pathetic in the extreme and will desperately disappoint GPs and primary health care workers in London, who can take no comfort from the pathetic provision of only £28 million a year to introduce and improve services?

Mrs. Bottomley

The hon. Lady's remarks are such irresponsible, misleading gibberish that I shall not bother to respond to them. She has been engaging in distortion. She cannot have listened to any of the constructive and helpful discussion that we have had this afternoon. I suggest that she read the report rather more carefully.

I confirm that our proposals are based on four central principles—that people who live and work in London must have ready access to the full range of services that they need; that services must be of a good standard and cost-effective; that the internal health market should work in London as elsewhere; and that high-quality medical education and research must be sustained and fostered. Those are the principles of this report, and they are the principles that we shall see executed.

Several hon. Members

rose—

Madam Speaker

Order. We must now move on.

Mr. Clive Soley (Hammersmith)

On a point of order, Madam Speaker. I realise that there is a time problem, but several London Members, including myself, are confronted with the closure of Queen Charlotte's hospital and with the proposed closure of Charing Cross hospital, which would have a dramatic effect on my constituency. We have not had a chance to raise these matters. May I ask for an urgent debate? As the Secretary of State herself said several times, this is not just a London issue but a national issue. The debate that I seek should take place in Government time and should be arranged soon.

Madam Speaker

I share the hon. Gentleman's disappointment at the fact that I have been unable to call more Members. I went carefully through the list of hon. Members in whose constituencies there are hospitals that are affected, and I attempted to call them. I also attempted to call Members for constituencies throughout other regions, as this is, of course, a national issue. The number of Members that I was able to call was limited by reason of long questions and, I may say, long answers. The House shares my disappointment at my having been unable to call more Members.

Ms. Glenda Jackson

On a point of order, Madam Speaker. The question that I put to the Secretary of State referred to the Royal Free hospital medical school. Much to my surprise, it seems that the Secretary of State does not realise that there is a Royal Free hospital and a Royal Free hospital medical school. She chose to centre her reply on the Royal Free hospital. She implied that I had been critical of the service provided by that hospital. In doing so, she insulted not me but the medical and nursing staff—

Madam Speaker

Order. I heard the exchange to which the hon. Lady refers. She must know that it is a matter for argument, and not a point of order for the Chair.

Mr. Corbyn

On a point of order, Madam Speaker. I understand your difficulties with regard to the business of the House, as that is, unfortunately, the responsibility of the Government. The problem is that Londonders have no means of expressing a view before the Secretary of State starts radically altering and closing hospitals throughout London. There will be no consultation. No health authority covers London. There are no elections to the bodies concerned.

I appeal to you, Madam Speaker, to use your best endeavours to ensure that there is an urgent debate in which all these issues can be discussed before the Secretary of State goes ahead and implements a policy that has no support from the people of London.

Madam Speaker

Hon. Members, including the hon. Gentleman, know that the business of the House is not a matter for the Speaker. I have no doubt that these issues will be raised with the Lord President of the Council during business questions.