HC Deb 21 October 1993 vol 230 cc398-412 3.57 pm
The Secretary of State for Health (Mrs. Virginia Bottomley)

With permission, I wish to make a statement about the management of the health service in England.

Our health reforms are now firmly in place and here to stay. From next April, 90 per cent. of acute and community health services will be provided by NHS trusts. Patients are already benefitting from the freedom to innovate and improve which we have given to NHS trusts, to GP fundholders and to local health authorities. By passing responsibility down to local level, we have released the innovation and energies of those working nearest to users of the service. The result has been a fundamental shift of power towards the patient.

The priority now is to support better patient care through the continued drive towards decentralisation in the NHS. I have concluded that to do this requires changes to the management structures of the health service—structures which are largely unchanged since before the reforms. By streamlining management, we can also make substantial savings in administrative costs. These changes will maximise the proportion of NHS expenditure devoted to direct patient care.

My proposals for achieving these objectives are set out more fully in a background paper, copies of which are in the Vote Office. They follow the functions and manpower review which I announced to the House in May. I should like to place on record my thanks to Kate Jenkins and Alan Langlands, who led the review, and to their team, for the work they undertook.

A guiding principle of the review was that change should support the development of the all-important purchasing function. This function is now the distinctive role of district health authorities. Their job is to build up an accurate picture of what health services local people need, and to purchase services which best match those needs. Like GP fundholders, they have the power to change and to improve services. They lead the drive towards better quality care and better health in their areas.

A key feature of better purchasing is closer working between district and family health services authorities. It makes it easier to take an all-round view, to strike the right balance between hospital and community-based care and to improve public health. These authorities are already working in close partnership in many areas. We wish actively to encourage this.

I therefore intend, subject to Parliament's consent, to introduce a power to enable district and family health services authorities to merge. Such mergers will also eliminate duplication and produce savings in overhead costs, which can be spent directly on patient care. This will build naturally on progress locally.

It is clear, however, that, as the new system matures, strategic management above that level needs to be better tailored to a decentralised service. We need a lighter approach, geared to developing the potential of purchasing, while respecting local freedoms. It must also uphold and strengthen the national accountability of the health service.

Regional health authorities have served us well for nearly 20 years. I pay tribute to their chairmen, general managers and staff, who have led the health service through challenging times. The old hands-on style of the regions is, however, no longer appropriate. I therefore propose to abolish them. I will bring forward legislation to this effect as soon as parliamentary time permits.

In a national service accountable through the Secretary of State to Parliament, some strategic overview is required. For this reason, I also propose to reform the NHS Management Executive so that it can more effectively and efficiently discharge those functions which must remain the responsibility of central management.

The NHSME will remain within the Department of Health, but will take on a clearer identity as the headquarters of the national health service. It will be accountable, through its chief executive, to the Secretary of State for delivering against clearly defined targets and priorities. It will have precise responsibilities for strategic management and a straightforward structure to ensure cohesion and clarity of purpose.

Central management will continue to work with professionals to ensure that clinically high-quality and cost-effective practice is identified and systematically implemented, and that new health problems are tackled in a coherent way.

The national health service is the largest organisation in Europe. Its size, complexity and importance demand that central management operate through a regional structure. No institution in the world, private or public, would attempt to run such a scale of operation from a single headquarters.

I will therefore establish, as an integral part of a streamlined management executive, eight small regional offices. Each will be run by a director accountable to the chief executive. A regional structure will enable the NHSME to give more effective support to the development of local policies which provide high-quality health services to the standards set by purchasers, and the health service professions, and which ensure effective co-operation across service, education and research. The regional offices will also replace the existing outposts, and inherit their responsibility for monitoring trusts. We wish to build on the light touch approach which the outposts have successfully developed.

Like the outposts before them, the regional offices must be compact. I intend to set a limit on the total staff budget of each office, commensurate with its functions. A similar limit will be set for the Management Executive as a whole. the NHS needs strong management; but we must bear down on administrative costs to maximise spending on patients.

Health authority and trust chairmen have a key role as local leaders. They will be expected to play a prominent role in the new arrangements. We must also ensure a non-executive link between them and Ministers.

The NHS Policy Board will therefore be restructured to include additional non-executive members, each covering one of the eight new regions. These regional policy board members will provide a channel of communication to and from Ministers. They will be respected local figures, able to make a powerful contribution to ensuring that national priorities are delivered in their areas.

In light of the need for primary legislation, we expect the new arrangements to be fully in place by April 1996. We have plans, however, for making immediate progress towards a slimmer organisation. I propose to reduce the number of regional health authorities from 14 to eight by next April, and to align the boundaries of the remaining regions with those of the management executive's new regional structure. This will facilitate a smooth transition to the new system. Change will be managed to ensure that the effective day-to-day operation of patient services is maintained. Management cost disciplines and targets will be met at each stage.

Ten years ago, this Government introduced general management into the health service. The author of those changes, Sir Roy Griffiths, observed then that it cannot be said too often that the National Health Service is about delivering services to people. It is not about organising systems for their own sake". That principle, above all, has guided the changes that we have announced today.

These changes will slim down NHS management. They will make it simpler and sharper. They will clarify its precise roles and responsibilities, and ensure that it delivers results measured against explicit targets. They will save money on administration to spend on patients, and they will uphold and strengthen accountability. They will continue the process of decentralisation and support the development of high-quality, cost-effective health care.

A better managed health service means better care for patients. These proposals turn the clock forward to more modern and more efficient management, building on the progress of our health reforms. I commend them to the House.

Mr. David Blunkett (Sheffield, Brightside)

I thank the Secretary of State and her office for their courtesy in allowing me to have the statement and the attached document earlier today.

Perhaps the Secretary of State will confirm who has been in office for the past 14 years, who is responsible for the growth in bureaucracy in the national health service, and who created the National Health Service Management Executive and spent £55 million on establishing an office in Leeds and an equivalent sum on severance payments and travel costs.

Who set up the NHS trusts which led to an explosion in the number of managers, administrators and accountants? Who created 18,000 non-caring, non-patient-oriented posts at a time when 8,500 nurses were losing their jobs?

How much more money, on top of the £1.2 billion that has already been spent on NHS changes, is to be allocated to these further moves in what the Secretary of State has described as her new system? Whose system has increased waiting lists to a record 1,031,000? Who increased waiting times over the first quarter of the financial year and has created a two-tier system which the royal colleges and the British Medical Association rightly condemn? Who has demoralised staff with change after change and uncertainty after uncertainty, and who has allowed the market and competition to prevail over democracy and accountability? Where in the statement is there anything about local or regional accountability? Can the Secretary of State point to any suggestion that patients will receive a better service or improved treatment, or that they will find more money allocated to care?

Will the Secretary of State spell out a little further the way in which the regional boards which currently operate will be replaced by "respected local figures"? Those respected local figures will have responsibility, as spelled out in the attached document, for the appointment of members of the trusts and health authorities, and will account for themselves only to the new expanded NHS Policy Board. They will be gauleiters on an NHS politburo—that is what it amounts to.

Why should non-elected, non-accountable, non-democratic individuals picked out by the Secretary of State be responsible for running our service? is that not nepotism and bureaucracy gone rampant, with administrative regions replacing the present appointed regions, and individuals replacing those who sit on executive boards?

Will the Secretary of State spell out in greater detail paragraph 17 of the attached report? As she mentioned in her statement, it says that the headquarters of the health service will be at the Management Executive. What will the relationship be between the Management Executive and the Department of Health, between the outposts which make up the new regions and the Policy Board and the Department of Health? What will be the functions? Where will the responsibilities lie? They are not spelt out in the statement or the attached document. We are told that we must wait until 31 July 1994.

Where is the saving of money? How many jobs will be redeployed locally and regionally? How many jobs are to go? How much will it cost us in redundancy pay? How many savings shall we seek from the new "light touch"? Does the euphemism "light touch" mean the abandonment by the Secretary of State and Ministers of responsibility for running the service? Competition, commercialisation, nepotism and centralism are built large in a statement that purports to look after the interests of the patients.

It has recently been revealed by the chairman of the Audit Commission, appointed by the Government, that in some hospitals it takes six people to change a light bulb. How many civil servants will it take to change the Secretary of State's mind? There is no democracy, no co-ordination. Where in the statement or the attached document can the Secretary of. State point to any mention of planning of change, of co-ordination or vision of a strategy for the health service for the next 20 or 25 years? This is a shoddy statement, from a Secretary of State who is a spent force. We shall expose, attack and denigrate the fraud that is inherent in the statement this afternoon.

Sir Anthony Grant (Cambridgeshire, South-West)

He thinks that the shadow Cabinet elections are still on.

Mrs. Bottomley

My hon. Friend has it right. The appointments to the shadow Cabinet must be motivating the hon. Gentleman.

We always know what the hon. Gentleman is against—we have had another dose of vituperation and abuse—but none of us on this side of the House is any the wiser about what he is in favour of. The long-awaited policy document from the Labour party will be an interesting experience. Perhaps the hon. Gentleman is trying to reopen the battles between Nye Bevan and Herbert Morrison in 1948 about whether local government should have control over hospitals. We wait for that gap to be filled.

Much more important is the fact that I have an opportunity to address some important points. Let us be clear about the achievements of the NHS in recent years, and about the fact that those achievements are largely thanks to NHS managers. For every 100 patients that were treated before the reforms, 116 are now treated. The hon. Gentleman mentioned waiting lists. In the last year alone, the number of people waiting more than one year has fallen by 20 per cent. Before the reforms, about 170,000 people were waiting for more than a year. The figure is now down to below.70,000. The reforms have been a major success, due in large measure to the dedication and commitment of NHS managers.

The hon. Gentleman never fails to take a cheap swipe at NHS managers. He quotes a figure of £1.2 billion but fails to acknowledge that the figure includes funds for the appointment of 100 consultants. The hon. Gentleman may think that those 100 consultants should not have been appointed.

Also contained in that £1.2 billion was a great deal of money for clinical audit and for the development of good practice. About one fifth of the money was concerned with the establishment of the NHS reforms. The benefits in terms of the improved quantity and quality of patient care have more than justified that relatively modest investment.

The hon. Gentleman spoke about accountability. Accountability in the NHS goes not only to the Secretary of State, although that will remain. Paragraph 17 states that it is not in our view appropriate to establish the NHS as a next steps agency. It is a service of great sensitivity and, understandably, hon. Members want the Secretary of State to be able to address issues that affect their constituents.

However, the hon. Gentleman—who is signed up to a command and control model—fails to understand the significance of the decentralisation down to the local health authority. That will now be strengthened by the integration with family health services authorities, allowing primary and secondary care to be dealt with by one authority. That is where accountability lies. The local health authority is the champion of local people.

My hon. Friend the Minister for Health has explained much of the thinking around the development of purchasing and the strategic shift, so that we can think of health and not only of institutions.

There has been a substantial increase in the number of authorities that are reporting to the public and making their accounts available for audit by the Audit Commission. The 400 NHS trusts will have their own boards and their own annual meetings to which the public can go. There has been a revolution in the amount of information that is available about the NHS.

The changes that we have introduced are the natural next step. The NHS reforms have been a great success, and the changes will ensure that management will see the further evolution of the reforms and will release, rightly and properly, more money for patient care.

Several hon. Members

rose—

Madam Speaker

Order. That exchange took precisely 19 minutes. I will now expect brisk questions from Back Benchers and brisk responses from the Secretary of State.

Mrs. Marion Roe (Broxbourne)

May I congratulate my right hon. Friend on her statement, and particularly on her offer to merge DHAs and FHSAs, which will be widely welcomed? Does she agree that, in the modern NHS, it is vital that an all-round view is taken of patient needs, including which services should be provided in hospitals and which in the community?

Mrs. Bottomley

I agree entirely with my hon. Friend, who has the answer precisely in hand.

Mr. Terry Davis (Birmingham, Hodge Hill)

Is the Secretary of State aware that the most visible results of her policies in Birmingham last week were patients lying on trolleys all night in the accident and emergency unit at Heartlands hospital, because there were no beds for them? That happened not just on one or two nights, but on three nights.

Is she aware that people were being resuscitated in corridors? Is there anything in her announcement that will help to put an end to that scandal at what was the first hospital in Birmingham to become a trust?

Mrs. Bottomley

Every year, the health service treats 46 million patients. The vast majority of those patients are extremely appreciative of the care they receive. There are times when things go wrong, and when they do, it is important that the problem should be understood and urgently addressed. In Birmingham, as in many inner-city areas, there is a great legacy of hospitals from the past. As we see the strategic shift increasingly to primary care and care in the community, identified by my hon. Friend the Member for Broxbourne (Mrs. Roe), we need to take forward those changes and invest in the patient care of today and tomorrow.

Dame Jill Knight (Birmingham, Edgbaston)

Have not there been great criticisms to the effect that too much money has been spent on administration and not enough on care? Does not today's statement address that point, as well as representing a further stage on the road towards sensible and wise economies in the health service? Can my right hon. Friend, first, say what money we can save, and, secondly, confirm that every penny of it will go on patient care?

Mrs. Bottomley

Earlier this year, I announced that the regions should bring their numbers down to about 200 from about 570. There has already been a 14 per cent. fall in the regions' budgets this year and the changes that I have announced will take that forward significantly, so that every penny can be spent on patient care, as my hon. Friend rightly asks that it should be. We have a health service that is directed towards meeting the needs of patients to the best of our endeavours.

Mr. Dennis Skinner (Bolsover)

Is the Secretary of State aware that the Heath Government—the Tory Government—of the early 1970s decided to reorganise the health service, and spent a small fortune of the taxpayers' money? Is she aware that the net result has been that, in the past 14 years, the Tory Government have tampered with the service several times, and that what she has announced today does no more than create bigger and bigger quangos, at a time when quangos already take about 20 per cent. of public expenditure in Britain?

We do not want any lessons in democracy from the right hon. Lady, who holds her position not as a result of election but as a result of patronage, and whose arrogance is shown by the fact that she calls upon Marks and Spencer to open early—something that Thatcher and the Queen have never demanded. If the right hon. Lady wants some democracy, why does she not have the health authorities elected half by the community directly and half by those who work in the health service? That would be accountability, and it would be democratic.

Mrs. Bottomley

The model of management that the hon. Gentleman advocates would be a recipe for disaster for the patients involved. There are difficult decisions to be made in health care. The health service is an organisation consisting of 1 million people. It spends a budget of nearly £30 billion, and that requires good and effective management. The hon. Gentleman was reopening the old debate that took place between Nye Bevan and Herbert Morrison back in 1948.

We are witnessing improvements in patient care. We are also announcing a reduction in the number of authorities because of the way in which the reforms have progressed. Trusts are a very much better model. What we want now is for purchasers to champion the interests of patients and secure progressive improvement's in the care that they provide.

Mr. Roger Sims (Chislehurst)

Is my right hon. Friend aware that the results of her shopping expeditions are much appreciated on both sides of the House?

Is she also aware that, in Bromley, the family health services authority and the district health authority have for some time worked closely together, with premises and a chief executive in common, and that that has led to greater efficiency and to more money being available for patient care? Will she encourage the integration of DHAs and FHSAs in anticipation of the legislation, so that we do not have to wait the two and a half or three years that it will take for it to be implemented?

Mrs. Bottomley

Indeed. I thank my hon. Friend for his remarks, although only a month or two back I was being castigated for buying my clothes in second-hand clothes shops supported by mental health charities in my constituency. I was grateful to Marks and Sparks for offering to let me come in early, although—on a point of clarification—not opening early.

On my hon. Friend's serious point, I am sure that the merging of DHAs and FSAs will be widely welcomed. I thought it more than a little mean-spirited of the hon. Member for Sheffield, Brightside (Mr. Blunkett) not to give that proposal a warm welcome. In searching the documents desperately to ascertain what the Labour party's health policy might be, I discovered a document entitled "Your Good Health" dating from February 1992, which advocated a common health authority for primary and secondary health care, so it is a shame that the hon. Gentleman could not bring himself to give a warm welcome even to that proposal.

Ms Liz Lynne (Rochdale)

Does the Secretary of State accept that the plans for regional health authorities will lead to more centralisation rather than less, and will take away any little accountability there may be in the health service? Does she also accept that, with the merging of the district health authorities and the FHSAs, district health authorities ought to be conterminous with local authority boundaries? Instead of appointing people to the boards, will she make a commitment to direct elections, to enable some accountability in the health service?

Mrs. Bottomley

I must make it clear that the whole purpose of the change is precisely to devolve responsibility to district health authorities, who champion the interests of local people, who establish contracts that are available to the public, and who work with general practitioners to secure improvements in the contracts year on year. The regions are a part of the history of the old command and control style. It did a good job for that sort of health service, but, if we want an evolving health service which is responsive to local needs, we must ensure that the district has the authority.

The advantage of direct elections to health authorities is a myth. I have said time and again that that aspect was rejected when the NHS was first drawn up. I do not think that anybody can seriously believe that the health service would benefit from that party political process. [Interruption.] Running the health service is a difficult job. The hon. Lady might wish to listen more than she shouts and speak to the many members of her party who are serving on health authorities and on trusts. I can give her and the hon. Member for Southwark and Bermondsey (Mr. Hughes) a great list of names of people in their party who are doing a magnificent job championing the interests of local people. Those people will not be grateful to her for denigrating the seriousness with which they undertake their work.

Mr. David Martin (Portsmouth, South)

I welcome my right hon. Friend's decision to abolish regional health authorities, but is she aware that it is still the perception of many members of the public, as well as many people working in the national health service, that there are too many administrators? Will she ensure, as the reforms go through, that we see savings that build up not only those at the sharp end of patient care, but patient services?

Mrs. Bottomley

I thank my hon. Friend for his point. We are to maintain tight budgets on administrative and overhead costs as we go forward with the further development of the reforms. My hon. Friend might like to know, however, that, of the whole budget for staff costs, about 3 per cent. goes on managers—general managers and senior managers—and 65 per cent. on direct care staff.

Mrs. Alice Mahon (Halifax)

The Minister will be aware that waiting lists in the Yorkshire region have increased considerably. Will she tell us how the abolition of the RHAs will help? Are not longer waiting lists evidence that the changes have failed? Will the executives who are to be employed in the new outposts have to include their Conservative party card in the application?

Mrs. Bottomley

That last comment was rather cheap. The hon. Lady might like to know of the great number of people from her political party who are doing a magnificant job—and have for many years—working for various authorities and various trusts.

Clearly, the patients in Yorkshire want the maximum amount spent on patient care and the minimum but necessary amount spent on overhead costs. We believe that we can streamline the services to ensure that we put more into patient care and continue the impressive improvements in the quantity and quality of patient care, in the falling waiting times and in the further developments that we have seen since the reforms were put in hand.

Mr. James Couchman (Gillingham)

My right hon. Friend will find no apologists on the Conservative Benches for the overblown bureaucracy of the present regions. She will know that South East Thames regional health authority has made its highest priority the capital investment of some £50 million in the Medway hospital in my constituency. Will she assure me and my constituents that the capital decisions that it has taken will not be thrown back into the melting pot as a result of her announcement today?

Mrs. Bottomley

I see no reason why the decision that I have announced today should jeopardise my hon. Friend's project. The statutory regional health authorities will remain until the anticipated legislation is completed, which will take a further two and a half years. We expect to merge the regions on those anticipated patterns in the next six months or so.

Ms Hilary Armstrong (Durham, North-West)

Is the Secretary of State aware that patients in north-west Durham will greet with incredulity her statement that her reforms are meant to be in their interests?

Mr. Keith Mans (Wyre)

How do you know?

Ms Armstrong

I know because I live and work with them. Under previous reforms, their services have diminished and disappeared, and accessibility to them is diminishing daily.

Will the right hon. Lady assure me and them that the accident and emergency unit at Shotley Bridge hospital will be kept open, and that they will have access to that hospital and its services, which have served them well over the years?

Mrs. Bottomley

The hon. Lady will know that every part of the health service must face change. Tomorrow's service configurations will not be what they were yesterday. There used to be 200,000 TB beds in this country. If we want to invest money in mentally ill people in the community, to develop services for HIV-positive patients and to develop and pioneer new innovations, we must have regard not only for the traditional ways of providing services but for the royal colleges' studies into the most effective and safest ways of providing a service.

The hon. Lady should tell her constituents that, before the reforms, the average length of wait across the country was nine months. That has now been reduced to five months. The immunisation programme has saved hundreds of thousands of children, and the cancer screening programme has been developed and extended. Since the reforms were set in hand, an extra £9 billion has been made available for the health service.

Mr. Jerry Hayes (Harlow)

I warmly welcome my right hon. Friend's radical and common-sense proposals. Does she find it remarkable that not one Labour Member is capable—they are probably medically incapable—of welcoming good news for patients? Will she spell it out to them that, if they oppose these proposals, they will be supporting bureaucracy, which is no surprise, but not supporting decentralisation and more money for patient care? That is a tragedy.

Mrs. Bottomley

Yes, I suggest that Labour Members read Hansard tomorrow to study my hon. Friend's comments.

Mr. Nigel Spearing (Newham, South)

But does not the Secretary of State realise that this is not a reforming statement but a deformation of the health service? Is she not substituting a public service that is locally accountable with a maelstrom of contractors? There will be little choice for patients; all the choice will be for purchasers. Apart from the Secretary of State, who appoints those purchasers, and to whom are they accountable?

Mrs. Bottomley

The hon. Gentleman seems to fail to appreciate that, whereas in the past the chairman of a health authority was primarily concerned with running the institutions within that authority—that dominated the agenda—his task now is to assess the health needs of the population, to establish a strategy to ensure cost and quality-effective services across the range. He is no longer preoccupied with the institution; his task is now dominated by the interests of patients.

That is a very important strategic shift in the delivery of health care, which has been recognised time and again. The health authority is the champion of local people. Its job is to participate and to take note of the views of local people, so that it can take forward those changes. The hon. Gentleman should not underestimate the significance of that strategic shift, which champions the interests of patients. As with the hon. Member for Rochdale (Ms Lynne), if the hon. Gentleman would like a list of the many distinguished members of his party who have seen the opportunities and have a vision of how the improvements can be taken forward, I shall be more than happy to give it to him.

Mr. John Whittingdale (Colchester, South and Maldon)

I congratulate my right hon. Friend on her statement, which will be welcomed by all districts, particularly north Essex. Will she confirm that she will continue to move towards funding of districts on the basis of weighted capitation, and that this will be determined by a single national formula, without additional factors built into it by the regions?

Mrs. Bottomley

I am well aware of the strength of feeling among the districts and trusts about the burden of overhead costs. We are moving towards weighted capitation, which will continue to be the policy, subject to the framework set by Ministers.

Mr. Hugh Bayley (York)

How can it possibly be decentralisation to concentrate power in fewer regions which are directly accountable to the management executive and do not meet in public? I asked the Secretary of State a question last year about the future of the regional health authorities, and she said:

The role of the regions will remain as it is".—[Official Report, 12 May 1992; Vol. 207, c. 486.] Was the Secretary of State misleading the House? Why has the situation changed? Does she realise that the regions are responsible for commissioning regional specialty services such as cardio-thoracic surgery and neonatal intensive care?

The Government have spent not a small but a large fortune dividing the health service between purchasers and providers, and now, at regional level, they are bringing together in one body the purchasing agency, the regional health authority, and the provider agency, the regional arm of the Management Executive. Is that not an admission of the failure of the purchaser-provider split?

Mrs. Bottomley

The hon. Gentleman should study the document, when many of his points will be clarified. The role of the region is not command and control, or to dabble in the day-to-day affairs of the districts and the trusts. The new regional offices of the Management Executive will have the strength to bring together intermediate-level interests—which will address the hon. Gentleman's points—but the power goes to the districts, which are the champions of the local people and set the purchasing strategy. Intermediaries should only intervene by exception, or to set a strategic framework, or to arbitrate in disputes. It will be a question of exception, not the command-and-control structure of the past that fossilises health care.

Sir. Dudley Smith (Warwick and Leamington)

I warmly welcome my right hon. Friend's proposals. In view of the near-criminal financial irresponsibility of the old West Midlands regional health authority, and the allegations in the past few days of severe financial incompetence on the part of the old South Warwickshire health authority, will my right hon. Friend give an undertaking that the new bodies set up to replace them will be subject not only to auditing but to close monitoring where public money is concerned?

Mrs. Bottomley

My hon. Friend is right. Those charged with spending public money on a service as important as the national health service should operate the highest standards of public service. My hon. Friend will know that we have set up a task force on probity, accountability and openness. The Government's corporate principles are set out in the Cadbury report, and a report will shortly be produced for use throughout the health service.

I share my hon. Friend's concern. The vast majority of people in the health service are deeply committed to providing improved patient care, but when anything goes wrong, it is right that we should leave no stone unturned in setting it right and learning lessons.

Mrs. Bridget Prentice (Lewisham, East)

Who are the local worthies who can now make the difficult decisions in the national health service that cannot be made by people who would be accountable by being elected? Can the "shop alone" Secretary of State also tell us why, given the chaos that she has created in London's health services, she has not created a regional health authority for London?

Mrs. Bottomley

We have been round this issue fairly often, and perhaps one Opposition Member might be able to think of a different question to ask. Members of the Labour party, like members of all parties, are welcome to submit names for health authority appointments; they come from many different regions. I have to give the same answer that I gave before—that, if any Opposition Members wish, I can put them in touch with many of their party associates who are involved in the improvements. [HON. MEMBERS: "We have heard the answer before."] I have heard the question before, and I am afraid that Opposition Members have to hear the answer again.

I am more than happy to discuss the important subject of London. London has special needs, and its 45 hospitals, which include many teaching hospitals, have special circumstances, but the problems are best tackled by maintaining South Thames and North Thames regions, so that the people involved in those health authorities are aware of the pressure of the outlying districts of the home counties, which are supporting health care in London to the tune of £100 million this year. It is important to keep that process in place.

Mr. James Clappison (Hertsmere)

Is my right hon. Friend aware that all those who wish for strong local purchasing will welcome the announcement that she made today about the powers of DHAs and FHSAs? Those people include patients in south-west Hertfordshire, who already enjoy the benefits of a strong local purchaser. Does she agree that the reforms that she announced today will help managers and professionals to work together with purchasers to promote high-quality care and the best clinical practice?

Mrs. Bottomley

Yes.

Mr. Derek Fatchett (Leeds, Central)

Will the Secretary of State clarify a subject that was unclear from her statement? Will she give some sign as to the future employment prospects at Quarry house in Leeds for the National Health Service Management Executive? Will she dispel the rumours in Leeds that hundreds of jobs are to be lost at Quarry house? Having spent £55 million on a new building, any Government that can plan their business so badly that they create those jobs, relocate the staff and then lose jobs within a matter of six months are wholly incompetent and do not deserve to be in office.

Mrs. Bottomley

People who work in Quarry house are very concerned that the hon. Gentleman—of all people —should have been the first to undermine their arrival in Leeds. Any organisation of the size and complexity of the national health service needs a headquarters office, and any Conservative Member would have welcomed all those people coming to Leeds, rather than, from the word go, making them feel unwelcome and undervalued.

As to costings, the relocations to Quarry house will bring about substantial savings. There were 25 sites all told in London, and the move has substantially reduced the number of sites, which will lead to savings of about £10 million a year once the immediate costs have been met. The people in Leeds, like the people in regions, will have discussions about how those changes effect them. They are having discussions at this moment. It is not possible to give precise figures, but we need a health service with appropriate management. We have moved on from the reforms. There are new challenges and new needs.

I urge the hon. Gentleman to take pride in Leeds as the headquarters of the national health service and not to seek every opportunity to denigrate and undermine it.

Mr. James Pawsey (Rugby and Kenilworth)

The reforms that were announced by my right hon. Friend this afternoon were extensive. Will she elaborate on what she intends to do to improve accountability to the community, to Ministers and, through Ministers, to the House? It may help my right hon. Friend to know that I am thinking especially of proposals that might be put forward by health authorities to regrade or close hospitals.

Mrs. Bottomley

My hon. Friend is a champion of the services in his constituency. It is important that district health authorities, especially when they merge with FHSAs, work hard to secure the involvement and participation of local people. Many Opposition Members mentioned elected representatives on health authorities. I do not believe that that is the right way forward, any more than Nye Bevan did; I believe that the right way forward is proper communication and understanding with local authorities, and especially with the Member of Parliament. The community health council has an important role to play. If a proposal does not meet with the agreement of the community health council, it comes to Ministers for decision.

Mr. John Gunnell (Morley and Leeds, South)

It is precisely because I was appointed to a health authority that I would express concern about one aspect of the strucyture that the right hon. Lady put forward., Will she explain how the eight people who will liaise with her will be responsible for the appointment of 540 boards? In those circumstances, how can those eight people be other than people who are acceptable to Conservative central office? Will not the changes centralise political control but fragment the strategy for health care?

Mrs. Bottomley

As I understand it, there has been little change for many years in the way in which chairmen are appointed, whatever political party has been in control. I pay a warm tribute to those people who, selflessly and with tremendous energy, have been so successful as chairmen either of NHS trusts or of DHAs or FHSAs.

The answer lies in hon. Members' hands. If they know of people who have the dedication, energy and commitment to serve in that way on health authorities, they must submit their names.

Mr. Anthony Coombs (Wyre Forest)

Is my right hon. Friend aware that the abolition of regional health authorities will be warmly welcomed in my constituency? There the Government health reforms have led to both hospitals adopting trust status, 80 per cent. of the population are now treated by GP fundholders and there is a better standard of services in acute and primary medicine than ever before.

Can she assure the House that there will be no transfer of staff, automatic or otherwise, from regional health authorities to the regional offices of the health service executive? In that way, administration in the national health service will be reduced and patient services will be improved.

Mrs. Bottomley

The new regional offices will be on the model of the zonal outposts which have been monitoring the trusts. That light approach is the one that we wish to pursue. I am delighted to hear of the successes in my hon. Friend's constituency, as he knows that, from next April, 90 per cent. of our provider units will be NHS trusts, leading to better care for patients.

Ms Tessa Jowell (Dulwich)

Does the Secretary of State accept that the market created by her health reforms in London is creating chaos with the well-being and serenity of hundreds of thousands of patients who depend on London hospitals for their treatment? Will she give an assurance today to the 500 patients at the kidney unit at King's that they have nothing to fear, that their treatment at King's will continue unimpeded, and that a threat no longer hangs over the unit, which is their lifeline?

Mrs. Bottomley

I cannot give that assurance to the hon. Lady, and she knows why as well as anyone. In the past 80 years, 20 reports have said that there had to be change in London. No change is no option.

One of the great problems in London is that local people were deprived of routine district general hospital services because of the tremendous multiplication and fragmentation of specialty services. I am deeply concerned about the uncertainty that inevitably has to continue a little longer in some of the hospitals.

We have had independent reviews from research and from clinical experts, and we shall take decisions in the near future as to how we can take forward health care in London. In order to release resources for routine care for the men, women and children of London, we have to tackle that problem. The hon. Lady knows that as well as anyone in my Department.

Mr. Richard Alexander (Newark)

Is my right hon. Friend aware that the first part of her statement will be widely welcomed by those working in the health service at grassroots level, but that the second part might be less welcome? In view of the fact that district health authorities are responsible for their budgets and for ensuring health care, is there really any need for continuing the layer of bureaucracy over their activities? Could we not grasp the nettle and scrap the lot now?

Mrs. Bottomley

My hon. Friend is asking me to go further, faster, than anyone else in the House. He has rightly identified the resentment at the unnecessary layer of bureaucracy above the local health authority and provider units, which must have the greatest significance. Frankly, there is a role for a strategic body—an intermediate tier—to intervene in the market where appropriate; for example, to ensure that specialty services are properly identified or to intervene in disputes. However, it must mean intervening by exception rather than the command-and-control, rather stultifying approach of the past. We are determined that greater resources for direct patient care will come out of it.

Ms Dawn Primarolo (Bristol, South)

Will the Secretary of State explain why she praises managers in the national health service but then announces that she is going to sack them? Does she agree that her definition of decentralisation means the break-up of the national planning structure for the NHS? Will she explain what will happen to strategic planning and public health policy when she abolishes her new regions?

Finally, how many doctors' posts will be created as a result of her changes? The right hon. Lady surely must be aware that we have the lowest ratio of doctors—1.4—per thousand of population in Europe. Is her hidden agenda to privatise the health service by the end of the century by using a next steps agency?

Mrs. Bottomley

I have made it clear that we are not establishing a next steps agency. In characteristic style, the hon. Lady seems to think that no one in any organisation should ever have their job reviewed. That is only what I would expect from her, as she has totally sold out to the health unions and is blinkered from the needs of patients.

I respect, and have a great debt of gratitude towards, many extremely able health service managers, but one has to have the structure and management lines appropriate for the organisation—it is not a job creation scheme which never changes for fear of anyone being put in any short-term difficulty. Of course it is our intention to invest extra money in patient care, whether through nurses or doctors.

Finally, clear priorities and planning guidance are sent out. They are approved by me, as the Secretary of State, and sent out by the national health service. We have made it clear, as the hon. Lady will see when she studies the documents, that we want more explicit targets and better measurements of outcome, rather than merely measurements of inputs. All the Opposition think about is jobs for the boys and girls, and the union interest. We think about patient care and output from the service, and that is what we want to hold the health service to account for.

Mr. Jeremy Corbyn (Islington, North)

On a point of order, Madam Speaker. A month ago, as the chair of the London group of Labour Members of Parliament, I wrote to the Secretary of State for Health asking for an urgent meeting of London Members with her, to discuss the health service in London and the 150,000 people on the waiting list. One month later, I received a reply from the Minister of Health referring me to the health authorities in London as the only bodies competent to answer our queries. Is that accountability to this House, or is it fudging the issue?

Madam Speaker

The hon. Gentleman is attempting to ask a question which he had hoped to put directly to the Secretary of State for Health. It is certainly not a point of order.

Sir Anthony Grant (Cambridgeshire, South-West)

On a point of order, Madam Speaker. While I entirely accept your right and duty to select questions from whatever source you think fit—you have not been helped by the long-windedness of the two Front Benches—you will appreciate that no one from the East Anglian region has been called during our discussions of the health service. As you will appreciate, two world-famous hospitals—Papworth and Addenbrooke's—are in that region. Perhaps, when the subject comes up again, that will be borne in mind.

Madam Speaker

I shall certainly keep that in mind, but I must tell the hon. Gentleman—this is a good opportunity for me to place it on record—that I am always anxious for hon. Members who seek to question a statement to be here at the beginning of it. That is a courtesy to the Minister. Some hon. Members, whose names I have listed, were not in the Chamber at the beginning of the statement. Therefore, when I have a choice to make, I shall obviously select those who were in at the beginning.