National Health Service (London)

HC Deb 28 April 1994 vol 242 cc397-486

Madam Speaker

I have selected the amendment in the name of the Prime Minister.

4.13 pm

Mr. Frank Dobson (Holborn and St. Pancras)

I beg to move, That this House condemns the policies of Her Majesty's Government which are undermining the capacity of London's health service to care properly for all patients both from London and outside, to provide satisfactory training opportunities for doctors and nurses, to secure reasonable working conditions and job prospects for staff or to make adequate provision for research into improved care for patients and the promotion of good health.

Mr. Richard Tracey (Surbiton)

On a point of order, Madam Speaker. We are about to embark on a debate on the health of Londoners—a matter of great complexity—on an Opposition motion. How is it, then, that today's debate is to be led by the Opposition spokesman on transport? Surely that is an affront, and deeply offensive to Londoners.

Madam Speaker

As the hon. Gentleman is fully aware, that is not a matter for me, but it is an issue which could be raised in the debate.

Mr. Dobson

I start by declaring an interest. My family and I use our local hospitals. Our three children were born at the Middlesex hospital. They have since received accident and emergency treatment and in-patient treatment at University College hospital. One has received treatment at Great Ormond Street hospital. My wife has had both minor and major operations at the Elizabeth Garrett Anderson hospital, and I have been treated for minor injuries at both the Middlesex and UCH hospitals.

We have been fortunate in the care provided by our general practitioner at the Covent Garden medical centre, by health visitors and by the schools health service. We have been well served by the national health service in our area, and we want to see the same standard of service continue for everyone.

All is not well with the health service in London—not even Ministers can deny that. Never since the establishment of the national health service have Londoners been so concerned about what is happening to their health service, and they are right to be concerned.

The ambulance service is not working.

Mr. Simon Burns (Chelmsford)

Will the hon. Gentleman give way?

Mr. Dobson

I will give way, but I should warn hon. Members opposite that, on the last occasion that I opened an Opposition day debate about health, every Tory who intervened during my speech, bar one, lost his seat in the subsequent election.

Mr. Burns

I am extremely grateful to the hon. Gentleman for that warning. The day the Labour party wins my seat is the day that pigs fly.

Will the hon. Gentleman consider for one moment that, given the increase in spending on the health service, his party may be partly to blame for Londoners' concerns about health, because his party spends day after day maliciously running down the tremendous work of nurses and doctors and improved medical care in London?

Mr. Dobson

All I can say is that if the hon. Gentleman thinks that our campaigning and propaganda is so effective that we alone have managed to stir up Londoners, I hope that we are equally successful in every other sphere.

The ambulance service in London is not working properly. Hospital beds are being closed and whole hospitals are threatened with closure. Newly built wards are being kept empty and staff have been told to hold back on operations so as not to exceed their budgets. Doctors and nurses are made redundant, while hospital waiting lists are the longest ever recorded.

Scarcely a day goes by without reports—which appear frequently in the Evening Standard—of patients turned away from hospital, of people who cannot get out-patient appointments, of sick patients left waiting on trolleys all night because beds cannot be found, of elderly patients lost in a hospital, and of the ambulance service in chaos because its computerised command system does not work.

Health Ministers have a range of responses to these problems: "It didn't happen," "It's all scaremongering," or "It did happen and we are very concerned, but it's someone else's fault and we'll set up an inquiry."

Mr. Gyles Brandreth (City of Chester)

Will the hon. Gentleman give way?

Mr. Dobson

I will continue for a moment.

Only a few days before the total collapse of the London ambulance service's computer system, Health Ministers were telling the House that the problem was a behavioural matter with the staff rather than a technical matter with the computer. They said that an inquiry would serve no purpose. Five days later, the system collapsed and they had to set up an inquiry.

Never once have Ministers accepted any responsibility for what has happened to the health system. They have never once said that they got it wrong and that they are sorry. They pretend to a day-to-day infallibility which the Pope does not claim. Worse than that, they say that London is getting more than its fair share of health service resources, and that they will have to be cut.

Mr. Iain Duncan Smith (Chingford)

Will the hon. Gentleman give way?

Mr. Dobson

I will make a little progress first, if the hon. Gentleman does not mind—he should bear in mind my warning.

We must not blame the Secretary of State for the situation. The crisis in London's health service is a product of policies supported by the whole Cabinet. The Secretary of State has inherited policies originally introduced by the present Chancellor of the Exchequer. She has been left to pursue her search and destroy operation against London's hospitals—an operation which is the inevitable consequence of unleashing market forces inside the national health service at the same time as restricting the funds made available to would-be purchasers in the market. She has also had to try to reconcile the long-term strategic health care needs of Londoners with the—inevitably short-term—operations of that market.

I offer the House an example from my constituency. University College hospital and the Middlesex hospital are to be merged—that is quite right—and so are their medical schools. The total number of hospital beds in my area has been halved in the past dozen years, from over 2,000 to just over 1,000. This is a costly process and, until it has been completed and things settle down, costs inevitably will remain high.

The Secretary of State has said that, for strategic reasons, because its location offers such ease of access from all directions, the UCH accident and emergency department must be kept. The undergraduate medical school is rated the best in the country. The Government's specialty and research reviews give UCH top ratings, so anyone might reasonably expect the hospital to be safe.

The hospital is not safe, however, because the underfunded local health authority says that, to save money, it will have to send its patients for cheaper treatment further afield—in clear breach of the promises made by the right hon. and learned Member for Rushcliffe (Mr. Clarke) in 1990 about the right of GPs and patients to choose where the latter are treated, and about patients not being forced to travel further for treatment.

Several hon. Members

rose—

Mr. Dobson

I give way to the hon. Member for Chingford (Mr. Duncan Smith), who I believe represents a London seat.

Mr. Duncan Smith

Perhaps the hon. Gentleman could get us off on the right track, first by telling the House how much is spent per patient in London, and secondly, if Labour ever came to power, how much more per head would be spent.

Mr. Dobson

If the hon. Gentleman bides his time, he will hear some comparative figures for hospital spending in London and elsewhere.

The Government claim that London is over-provided with hospitals, so they propose more bed closures and hospital closures in London on top of those that they have forced through already. They say that this will not harm patients: that they are improving primary care instead. Let us examine those claims.

Does London get more funding than it is entitled to? The answer is no—not if we make allowance not just for the size of London's population but for the health needs of the population served by London's health services. For a start, London provides services—often the most expensive —for large numbers of patients from outside the capital. About 120,000 patients a year—10 per cent. of all patients treated in London district hospitals, and almost a third of those treated by special health authorities—come to London.

London has nearly 7 million people, 15 per cent. of the population of England. It has 1.1 million pensioners and about 1 million people who are poor enough to qualify for income support or family credit. In recent times, London's unemployment rate has been higher than the national average. Indeed, inner London has double the national average unemployment rate, twice as many one-parent families and three times as much overcrowding and poor housing.

Inner London's mortality rate is 25 per cent. above the English average. Three quarters of all AIDS cases are to be found in the Thames region, most of them in London. Almost the same figure applies for reported HIV infections. About one third of all drug addicts notified to the police are in London, and there are more than twice as many of them, per million people, as there are in the rest of the country.

Mr. Ian Taylor (Esher)

rose—

Mr. Dobson

I am trying to answer the question I have been asked.

Last year, the Secretary of State said: We spend some 20 per cent. more per head in London than elsewhere. That is not true, if London is compared with other big cities, and in the case of family health services it is just not true at all. Average spending per patient on family health services in England is £132 a year; in London, it is only £124.

Comparing total health spending per head in London with spending in other big cities, London, on £584 per person, comes after Manchester, on £791, Newcastle on £649 and Liverpool on £629. Those figures must be right; they were provided in an answer by the Minister who is replying to the debate. But that is not the whole story. Almost everything is more expensive to provide in London because of land prices, rents and London weighting of pay.

For example, policing in London is the sole responsibility of the Home Secretary; he is the police authority for London. London, with 15 per cent. of the population of England, gets 29 per cent. of the total spent on policing the whole of England. If the cost of the NHS in London in terms of land prices, rents and London weighting were similar to that of the Metropolitan police, the NHS in London could expect almost one third of the national total; but it does not get it.

Present figures suggest that London's share has fallen below 17 per cent. Today, the King's Fund, which has taken a hand in helping along the Government's rundown of health services in London, said that London merits a larger, not a smaller, share of the national cake. It suggests the sum of around £200 million.

Several hon. Members

rose—

Mr. Ian Taylor

On a point of order, Mr. Deputy Speaker. Would it not be in order, when some of us who seek to intervene have constituents in and around London, for the hon. Gentleman to give way so that we can get some common sense to him?

Mr. Deputy Speaker (Mr. Geoffrey Lofthouse)

The hon. Gentleman knows full well that it is not a point of order for me, but a matter for the hon. Gentleman who is speaking.

Several hon. Members

rose—

Mr. Deputy Speaker

Order.

Mr. Dobson

Since they came to power, the Government have relentlessly based their policies on the belief that London is overprovided. In 1979, there were 31,376 acute hospital beds in London. Today, there are just 17,181—a drop of 45 per cent. It is a truly gigantic reduction, yet Ministers claim this has not harmed patient care. That is difficult to reconcile with the fact that, over the same period, the waiting list for London hospitals has increased from 104,000 to 165,000, despite various administrative efforts to stop people getting on the waiting lists, and various administrative culls for those already on them.

More than 75 hospitals in London have already closed; 16 or 19 more are threatened, including Guy's and Bart's, University College hospital, Middlesex hospital, the Elizabeth Garrett Anderson hospital for women, Hammersmith hospital, Charing Cross hospital, Edgware general hospital, Barnet general hospital, Oldchurch, Queen Mary's Roehampton, Dulwich and Hither Green. I do not have time to name them all, not even the others in my constituency.

Mr. John Marshall (Hendon, South)

On a point of order, Mr. Deputy Speaker. Is it in order for an hon. Member to suggest that a hospital is to be closed when it has been made quite clear that that hospital will not be closed?

Mr. Deputy Speaker

Again, the hon. Gentleman knows the answer to that. The hon. Gentleman who has the floor is responsible for his own speech.

Mr. Dobson

In the past four years, one in five of London's accident and emergency units have been closed. Now accident and emergency services are threatened at Bart's and Guy's, St. Andrew's hospital at Bow, Harold Wood hospital, Queen Mary's Roehampton and the West Middlesex hospital.

Several hon. Members

rose—

Mr. Dobson

My hon. Friend the Member for Dulwich (Ms Jowell) made a series of visits to accident and emergency departments. She has been told by the staff that things are getting worse, and what they need most is better access to in-patient beds.

Everyone has heard of patients being kept on trolleys all night, but at Bart's last December, they did not just run out of beds: they ran out of trolleys. They had to dump an unconscious man on a mattress on the floor. On another occasion, to provide an intensive care bed for man brought in with gunshot wounds, Bart's had to unyoke an existing patient from his life-support machine and, because there were no beds at Bart's, he was transferred by ambulance to the Homerton hospital.

That is just one accident and emergency department, but such incidents are taking place all over the place. Some people dismiss these stories as anecdotes, but London knows that it is really happening.

Several hon. Members

rose—

Mr. Dobson

I shall give way to the hon. Member for Colchester, North (Mr. Jenkin).

Mr. Bernard Jenkin (Colchester, North)

I remind the hon. Gentleman that it was the last Labour Government who set up a working party to look into resource allocation, thus recognising that London had become over-provided. It may be that London is over-hospitalled, and we agree that it is under-resourced for general practices. But what are the hon. Gentleman's policies? He seems to be advocating the provision of mountains of extra cash for the health service in London. It is—

Mr. Deputy Speaker

Order. Interventions are supposed to be brief. This is an emotional debate, but Members on all sides will get a fair hearing. If it is obvious that an hon. Member is not prepared to give way, others must resume their seats.

Mr. Dobson

Then there is the deplorable state of the London ambulance service, which is by far the worst in Britain, falling far short of its performance targets. Ninety-five per cent. of 999 calls should be responded to within three minutes; in London, that is managed in only one third of cases. Half of all emergency ambulances should arrive within eight minutes; in London the proportion is only one in eight. Ninety-five per cent. should arrive in 14 minutes; in London this is managed in only two thirds of cases.

Let us be clear about the fact that people suffer as a result of these slow responses. Some suffer avoidable permanent pain or disability. Others die while waiting for an ambulance, while on the way to hospital or after arrival.

The Government say that all this rundown is necessary and just, and that it enables them to invest more in primary care. It is clear that more funds are needed for primary care in London, which, according to the Government's own figures, is under-funded compared with the rest of the country.

There are two flaws in the Government's argument. The first is that, in the period during which they have been claiming to shift funds into primary care, the number of general practitioners in London has actually gone down —and so, we believe, have the numbers of health visitors and district nurses. There has, however, been a 32 per cent. increase in the number of managers in the zones specially targeted for more funds.

The other fault lies in the Government's argument that more investment in primary care will reduce demand for hospital care. There is no evidence to back this claim. Indeed, common sense suggests quite the reverse. If more people can see a doctor, more are likely to be referred for treatment in hospital.

The idea of reducing the number of hospital beds in London to help general practitioners is not supported by GPs themselves. A poll of London's GPs showed that two thirds of them believe that the Government's proposals for health care in the capital will be detrimental to their patients. One third called for more funding for hospitals to increase the availability of beds, thereby enabling them to improve the quality of care for their patients. Like accident and emergency staff, they saw bed shortages as a major problem.

How can all this be going on if, as the Government claim, they are putting more funds into the NHS? For a start, the increase in London has been less than one third of the notional increase in the rest of the country. But that is only part of the story. So much NHS funding is now being wasted. Vast amounts are consumed, to no one's benefit, by the new bureaucracy needed to implement the Government's reforms.

In the four Thames regions, while the number of nurses has been reduced by 5,000, the number of management staff has risen by 5,700 nurses down by 5 per cent., managers up by 16 per cent; and managers are paid a great deal more than nurses.

This sort of change is an inevitable consequence of the new way of running the health service. Everyone predicted that it would lead to more bureaucracy, more paper pushing, more billing and debt collecting—and it has. As a result, the proportion of NHS funds spent on administration now exceeds 10 per cent. Ten years ago, predecessors of the current Ministers boasted that the figure was under 5 per cent. What a brilliant reform: doubling the spending on paperwork.

But this is not the only waste of money that has developed under the Conservative Government. Hundreds of millions of pounds has been spent on management consultants, public relations consultants, lobbyists—a whole rag-bag of Porsche drivers receiving outdoor relief at the expense of the patients.

Just recently, timed to coincide with the local elections, the Secretary of State issued a misleading leaflet about the health service in London. It has cost the taxpayer more than £250,000, and that amount should really be included in the election expenses of every Tory candidate in London. However, it is such a stupid leaflet that it probably did more harm than good. On top of that, the Department of Health now employs a good news unit, which spends its time plaintively ringing health authorities and trusts asking them to come up with good news on the NHS which Ministers can use.

Can the Secretary of State tell us what the people in that unit will be doing during the local and Euro-elections? Have they been redeployed into useful work, or are they still deployed producing good news stories for Ministers during the election period? I will give way to the right hon. Lady if she wants to tell the House about that. In parallel with that effort to promote favourable stories, the Government have tried to gag people working in the NHS to stop them revealing what is going on.

Another problem for the Government arises from their curious abandonment of the basic ideas at the heart of conservatism—with a small c. A real Conservative believes in letting well alone, not going for change unless the benefits of the outcome of that change would clearly exceed the bother and expense involved in the process. The Government's approach to the NHS, with its endless changes, owes more to the theories of Trotsky on permanent revolution or Chairman Mao on the cultural revolution than ever it did to Edmund Burke or Adam Smith.

The constant process of change in the NHS consumes an enormous amount of money, time and effort among those who are involved. It distracts them from doing their job of looking after patients, and consumes funds which could be spent on patient care.

Several hon. Members

rose—

Mr. Dobson

I shall certainly not give way to hon. Members who will raise spurious points of order, so that rules out a fair number, but I shall give way to the hon. Member for Harlow (Mr. Hayes).

Mr. Jerry Hayes (Harlow)

I have a simple question for the hon. Gentleman. Why on earth is he here? Is it to paper over the cracks because the Labour party has no policy at all on health, or is it because the Leader of the Opposition has no confidence whatever in the shadow spokesman on health? It is clear that the national health service would not be safe in the hands of the hon. Member for Sheffield, Brightside (Mr. Blunkett).

Mr. Dobson

It seems that spurious interventions have succeeded spurious points of order.

I have spoken about wasting funds, and I shall give an example from my constituency. University College hospital is on a good site, with the best possible access for emergencies, as the Secretary of State has confirmed. Over the past decade, under Government pressure, the hospital management has been forced to investigate the possibility of moving to no fewer than 12 sites, ranging from: on top of Euston station, to next to Great Ormond street, to Camden lock, and to knocking over Elizabeth Garrett Anderson hospital and building UCH there instead.

Money was spent on advice from consultants, architects, engineers and God knows who else, but no one has come up with an idea better than leaving UCH where it is. All that has cost a fortune, and it is the sort of thing that has been going on all over London. It is another terrible waste.

Mr. Harry Greenway (Ealing, North)

Will the hon. Gentleman give way?

Mr. Dobson

Not at the moment, but I shall shortly give way to the hon. Gentleman.

Of course, there is a fatal flaw at the heart of the Government's changes to the NHS: the introduction of what they call an internal market. That is based on the absurd proposition that health care is unique and that what is cheapest will also be the best. That is not true of a pair of shoes, a pair of jeans or a hotel.

If we decide to buy a cheap pair of shoes, we know that they will not be the best pair of shoes, but the Government want health authorities to place contracts with the cheapest hospitals rather than with the more expensive ones. But, as everybody knows, in many cases the more expensive hospitals provide better treatment. Heart bypass operations at one London teaching hospital may involve the death of one patient in 100. At other hospitals the death rate may be as high as four or five patients in 100, and the same applies in other specialties.

What right have Ministers and accountants to intervene and send patients to hospitals that are not the first choice of either the patient or the GP, and which both know are not as good? That also breaks another promise made by the Chancellor of the Exchequer in 1990.

Mr. Harry Greenway

Is the hon. Gentleman aware that, in 1987, the then Labour-controlled Ealing council put up rates on Ealing hospital by £330,000? That could have provided a lot of treatment for my constituents and the people of Ealing, but the council did not care. What does the hon. Gentleman think? He does not care either, when it really comes to it.

Mr. Dobson

Apparently, we have the self-answering question from the hon. Gentleman. If he wants to talk about Ealing, he might bear in mind for a moment the fact that hospital staff living in council houses have seen their rents double; they are now paying the highest rents in Britain.

But that is not the only problem that results from making hopitals compete for patients. At one time, all the institutions in the NHS used to work together for the benefit of patients. There were some silly rivalries, but they were on the periphery. Today, competition is at the heart of relationships within the NHS. Again, I want to illustrate that with an example from my area.

Following changes in the way that funds are allocated, the Bloomsbury and Islington health authority is set to lose a lot of its funding. All the local NHS managers are agreed on that—at the health authority, the family health services authority, University College hospital and the Middlesex, the Royal Free, the Whittington and Elizabeth Garrett Anderson hospital.

Together with my hon. Friends the Members for Hampstead and Highgate (Ms Jackson) and for Islington, North (Mr. Corbyn), I met various manangers to discuss the problem. We suggested that all concerned should get together to make representations to the Secretary of State. But the response was, "Oh, there's no chance of that. It's dog eat dog now in the NHS"—dog eat dog, in what used to be a national health service.

Supporters of the Government's policies can come out with all sorts of management blather about performance indicators and the like, but the instincts of Londoners are sound. They like their local hospitals. They take pride in the great teaching hospitals that have successfully combined service to local people with training doctors and nurses, and research and developments in treatment that have made them famous around the world.

Londoners are proud of London's hospitals, be it the Royal Free, the first free hospital, originally the London general institution for the gratuitous care of malignant diseases, or the Royal Marsden, the first to provide free cancer treatment for poor people, or the Brompton, the first to admit poor people suffering from tuberculosis.

Some time ago, when defending her efforts to close Bart's, the Secretary of State said that she was not responsible for the national heritage. Well, Londoners think that she is. Bart's was founded in the year 1123. It is part of our national heritage. It has been doing something useful for London for more than 800 years. It has been there longer than there has been a Parliament.

Bart's had been open for 400 years before Tyndale's English bible was first published. The Secretary of State may not want to do so now, but will she, in the quiet watches of the night, ponder whether she, who has not held her office for 800 days, should wipe out a hospital that has served Londoners well for 800 years?

This is make or break time for London's health services. Hospitals once closed will be hard, if not impossible, to reopen. Expert operating theatre teams once dispersed would be difficult, if not impossible, to bring back. Therefore, I implore the Secretary of State to go back to the Cabinet and to say, "We've got it wrong. We need to look at this again. We've got to make a fresh start. We must put the interests of Londoners before the interests of bureaucrats."

If the Secretary of State will not do that, Londoners will never forgive her. That is why Labour is calling for a freeze on all bed and hospital closures, and a genuine and open review of what must be done. Londoners need a health care system fit to meet the challenge of the 21st century, and the cuts must stop before it is too late.

4.44 pm

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

I beg to move, to leave out from "House" to the end of the Question and to add instead thereof: 'noting the rapid advance of medical science, population migration from Inner London and the increase in provision of specialist services outside the Capital, believes that the National Health Service must respond to these changes; congratulates the first government in 100 years prepared to tackle these issues; believes that the Government's long-term programme of strategic change is already leading to better services for patients, especially better primary care, and will strengthen centres of excellence in teaching and research and lead to a more sensible use of resources; and condemns her Majesty's Opposition for cynically treating the National Health Service in London as a party political battleground regardless of the interests of either staff or patients.'. If ever there was a case for the pamphlet that we have produced on the NHS changes in London, the hon. Member for Holborn and St. Pancras (Mr. Dobson) has just made it, although I fear that it must have been too complicated for him because his total ignorance, lack of understanding and deplorable, mischievous statements show that he needs an intensive programme of training and education. All that he could do in the end was to call for a 21st report into the problems of London—the 21st in the last 80 years.

The changes that confront the health service in London are necessary if patient services are to be improved. The changes are complex. They involve not just the health service but medical education and research, and they are long overdue. They do not lend themselves to the sort of soundbite cynicism that we have just heard from the hon. Gentleman.

Londoners deserve to know about the changes and why they have to happen. They do not need Labour's rants, riddled with inaccuracies, distortions and error. The hon. Gentleman's speech was typical of the Labour party's style. Labour Members provoke fear rather than inspire understanding; they are not interested in running the health service only in running it down; they are long on rhetoric, short on fact and devoid of understanding.

The hon. Gentleman brought to the debate all the wisdom and insight on health that one would expect from a spokesman on transport. The hon. Member for Sheffield, Brightside (Mr. Blunkett) has been forced to listen from the substitutes' bench. He has been binned in order to give his hon. Friend the Member for Holborn and St. Pancras a bit of pre-election lebensraum.

Earlier this week the hon. Member for Brightside asked about my position. It seems that he has now fled the field. He is the victim of a soft shoe reshuffle. We know, however, what the Labour party is up to. It is not interested in a debate about health; all it wants is a chance to boost its miserable campaign for the London elections. That is why the hon. Member for Holborn and St. Pancras opened the debate. He, after all, is its campaign cheerleader, a job he got, we recall, as a consolation prize for coming second to the hon. Member for Kingston upon Hull, East (Mr. Prescott) in the beauty contest. That speaks volumes for the Labour party's attitude.

Dame Elaine Kellett-Bowman (Lancaster)

Does my right hon. Friend agree that it may well be that the hon. Member for Sheffield, Brightside (Mr. Blunkett) did not dare put his nose here because he knows perfectly well that the north wants its fair share of resources? He dare not come here and yell that he wants more for London.

Mrs. Bottomley

My hon. Friend has it exactly right. What is more, the statements of the hon. Member for Brightside are already far too committed to the need for change so he had to be shuffled off before the debate took place.

Mrs. Bridget Prentice (Lewisham, East)

Will the Secretary of State tell the House when she last came to the Dispatch Box voluntarily and initiated a debate on health in London or elsewhere in the country?

Mrs. Bottomley

I should like to know when the hon. Lady last spoke to the House about the £25 million going into her local hospital. Somehow, Lewisham hospital is not mentioned in the House. That hospital is receiving enormous investment and showing great change and improvement.

Ms Joan Ruddock (Lewisham, Deptford)

Can the Secretary of State tell my constituents and those of my hon. Friend the Member for Lewisham, East (Ms Prentice) how their health services are to be improved as she suggests when the hospital on which many of them depend, Guy's, is to lose a minimum of 400 beds which are currently in use, and an accident and emergency department, and why at Lewisham hospital her accountants have created a situation whereby there are to be 70 compulsory redundancies, and highly skilled nurses are to be replaced by care assistants?

Mrs. Bottomley

The Labour party wilfully chooses to fail to consider the whole point because it considers only institutions. In the constituency of the hon. Member for Lewisham, Deptford (Ms Ruddock), in Southwark, Lambeth and in Lewisham, there are 200 primary care projects going ahead in the next five years. The hon. Member for Holborn and St. Pancras (Mr. Dobson) has 72 general practitioners in his constituency. Did we hear about the deprivation payments that they now receive—up to £30,000 for each GP in the hon. Gentleman's constituency? No, because, he, like the rest of the Labour party, voted against the new GP contracts. Did we hear that now 90 per cent. of children are immunised in the hon. Gentleman's constituency, as in the constituency of the hon. Member for Deptford? That figure used to be 70 per cent. before the new GP contracts and the Labour party voted against it. The Labour party is so obsessed with institutions because they are centres of the health unions. Every one of the Opposition health spokesmen is sponsored by one of the health trade unions. They do not want to undermine their power base. They do not speak for patients. They speak for the provider interests.

I must say that change is necessary in London and I hope to set out in greater length why that change is necessary. The outrage—

Several hon. Members

rose—

Mr. Deputy Speaker

Order. The Chair hopes to be able to hear what the Secretary of State has to say—[Interruption.] Order. I address my remarks to both sides of the House.

Mrs. Bottomley

I suspect that I have already given way a great deal more than the hon. Member for Holborn and St. Pancras. It is my natural instinct, when seeing such a blinkered ignorance, to wish to respond, but I understand that many Conservative Members are impatient for change, recognise the need for it and want to catch your eye, Mr. Deputy Speaker.

The debate is of great importance to London and to Londoners. Instead of a bona fide health spokesman, we get the performing political monkey. It insults Londoners, it insults their health service and it insults everyone working in that health service. So did the shameless behaviour of the right hon. and learned Member for Monklands, East (Mr. Smith), who wished to visit Bart's this morning, did not even have the courtesy to inform the local Member of Parliament, then wished only to go if he could go in a media circus. [Interruption.]

Mr. Deputy Speaker

Order. The House must settle down.

Mrs. Bottomley

It is the last Opposition day debate before the local elections. Those local elections concern housing, education, social services and transport. What does the Labour party choose to speak about? It chooses to speak not about the subject of those local elections—the fact is that it wants to conceal the performance of its local councillors—but about a subject which it always tries to wheel out every time it wants to raise its profile: exploiting the health service and wilfully misrepresenting the situation.

Dame Elaine Kellett-Bowman

Like Jennifer's ear.

Mrs. Bottomley

Like Jennifer's ear, as so many of my hon. Friends have said. The Labour party does not have a policy for the NHS in London that goes beyond next Thursday. Labour Members do not understand that Governments must measure their responsibilities in years and decades. Government responsibility is to patients and to the NHS staff who work for patients. Our responsibility to patients means that we have to look to health care in the future, rather than preserving, unchanged, every institution that has served us in the past. Our responsibility to staff means that we have to explain to them the need for change and help them to meet it. We have to reduce pressure on staff. No Government have done more than this one to reduce the unacceptably long hours worked by junior hospital doctors, ably helped by leaders of the Junior Hospital Doctors organisation from time to time and on which we have now spent £115 million. We have set up a clearing house to help staff in London who are affected by the changes to get new jobs.

First and foremost, our commitment must be to patients and I give an absolute commitment that services in London will change only for the better. Patients will receive more care, better care and closer to their homes. Professional staff will have the chance to respond to change, to provide care in different settings and to work in the NHS of the future. The health of London and of Londoners will steadily continue to improve.

Anyone who has studied those matters in detail—it is already clear that the hon. Member for Holborn and St. Pancras has seen very little and studied very little—knows that some of the needs for change go back 100 years. The hon. Gentleman and others have quoted Professor Jarman of St. Mary's hospital. I shall quote Professor Nick Bosanquet, who said that we must face change. He said: London health services may have had a glorious past but their quality in the future depends on our willingness to face up to difficult choices now. The Labour party has not shown a willingness to face any difficult choice at all.

Mr. Dobson

Just to correct the Secretary the State, I never mentioned Professor Jarman. If the right hon. Lady were to suggest that I have personally opposed changes in health services in my area, that would be a lie, because I was one of the first to suggest the amalgamation of the Middlesex and University College hospitals. When the North East Thames regional health authority said that it was ridiculous to have two regional cancer centres in my constituency, I agreed with it and believed that it was right that they should be transferred elsewhere. In the Labour party, we say yes, there needs to be change in the health service in London, but the changes that the Government are putting forward are the wrong changes.

Mrs. Bottomley

The hon. Gentleman fails to recognise that it is his health authority, in trying to assess the need of the local population, which is so anxious to put more resources not into hospitals but into the community—for example, an extra £500,000 into mental health services. That is why the authority wants to compare the costs of different hospitals, because if it gets better value for treating local patients, it can invest in further care. It is in the hon. Gentleman's constituency that I visited one of the most outstanding centres for people who have been resettled from Friern in Camden road. That is a multi-million pound project. There are a whole range of initiatives to help local people.

Mr. Brian Sedgemore (Hackney, South and Shoreditch)

The Secretary of State has a degree in sociology. That is the problem.

Mrs. Bottomley

I am grateful for the hon. Gentleman's intervention because he rightly says that I have a degree in sociology. I have two degrees in sociology —[Interruption.].

Mr. Sedgemore

That is the problem. [Laughter.]

Mr. Deputy Speaker

Order. May we have a little quiet below the Gangway?

Mrs. Bottomley

It is because I have two degrees in sociology that I believe that the way forward is to assess the local health need, not to allow policy to be dominated by the interest of the institutions—respected and loved though they have been—but to start from the interests of patients, from their health concerns and their social concerns, which Labour Members profess to support. Always, however, they resile from the analysis, they duck the difficult decision and take the populist way forward. They are interested not in patients or in staff but only in buildings.

It is no matter to Labour Members that there are 18 major hospitals in an area of central London where the population has fallen by 1 million in the past 30 years. It is no matter to them that there is duplication and fragmentation of specialist services, which weakens our medical excellence, splitting it between a plethora of different sites. It is no matter to them that GP services across the capital and services for the mentally ill have suffered decades of neglect, while the money has gone to support duplication in central London.

We can agree that there should be more primary care in London, but what the Labour party will not recognise is that if we are to invest more and more in primary care, we have to unlock the resources which are tied up in the battalion of big hospitals in central London.

Mr. Andrew Rowe (Mid-Kent)

Before my right hon. Friend gets on to the subject of primary care, does not she agree that the hon. Member for Holborn and St. Pancras (Mr. Dobson) made her point for her when he pointed out that the cost of providing health care in London is far higher than elsewhere in the country? To go on sucking patients out of constituencies such as mine into London quite unnecessarily is a gross misuse of national health service funds.

Mrs. Bottomley

My hon. Friend is exactly right. The average cost of a London teaching hospital is 46 per cent. above the cost of a teaching hospital outside London. That money has to be paid, but could otherwise be spent on providing services more cost effectively elsewhere. The Labour party ignores the extra length of stay of patients in London. It also ignores the way in which the population in London has left the centre and gone out to the suburbs. I know that many of my hon. Friends will be pressing to ensure that we make swift progress because they want a fairer distribution of resources. It also ignores the great network of hospitals that has built up around the home counties.

The Labour party not only shows ignorance about all of that, but disregards medical advances. For example, patients who previously had to be treated in hospital, perhaps for several days, even weeks, can now be treated as day cases and there are new diagnostic techniques, even in the community. All that means change. The Labour party may fail to understand that, but why has the number of hospital beds been falling for years in France, Germany the USA—all of which belong to the Organisation for Economic Co-operation and Development? The distribution of resources means a subsidy this year of £105 million, paid to support the hospitals in central London. If we do not act now, that subsidy will increase and will be needed year after year without improving services to patients. As my hon. Friend the Member for Mid-Ken (Mr. Rowe) rightly reminded me, it is the constituencies outside London that have to pay that bill.

Of course, that is only part of the picture. The subsidy is also paid for in investment forgone elsewhere in the capital. It could be better spent on more GP services, health centres, community nursing, care in the community and all the other local services that are vital to a comprehensive NHS. The Labour party, in effect, wants to sacrifice primary care to preserve each and every institution for all time. That policy is financially irresponsible and clinically illiterate, and Conservative Members will have nothing to do with it.

Mr. Simon Hughes (Southwark and Bermondsey)

I ask the Secretary of State a simple question. Does she accept that the cost of providing public services in the capital, by definition, is higher per capita than elsewhere, because the land cost is higher, salaries are sometimes higher and the incidence of deprivation in the London boroughs is considerably higher than in any other conurbation in the country? Does she accept that health care in London will always cost more and that, unless she is to ship all patients out of London, she will have to find the money for that additional cost?

Mrs. Bottomley

I accept that there are special needs in London; I particularly accept the need to invest in primary care in London. I do not accept, and if the hon. Gentleman is sincere, I doubt whether he does, the need, in the area where his constituency is, for four cardiac units within six miles, each beneath the size recommended by the specialty review. It makes no sense.

Mr. Hughes

Answer the question.

Mrs. Bottomley

I have answered the hon. Gentleman by saying that I accept that there will continue to need to be special support in London, but I am explaining to him, and to the Labour party, why some of the excessive and unnecessary costs in London have been the result of the duplication of specialist centres. One cannot have a cardiac centre at King's, Guy's, St. Thomas's and the Brook. It makes no sense and does not even provide the best research excellence. It certainly does not produce the most cost-effective care. Not only are there four cardiac centres in that small space, but half a dozen are within easy travelling time. Other Conservative Members will be appalled to think that there was such a duplication of cardiac investment, just to take one of a great number of examples, in such a small space. It is not cost-effective or clinically effective, and it undermines the ability to compete internationally in centres of research and teaching.

Several hon. Members

rose—

Mrs. Bottomley

In a moment.

The Labour party fails to understand that, as part of those changes, there is also a new £5.3 million cardiothoracic unit at Brighton—the residents used to have to travel all the way to central London for their cardiac care —which is part of the £35 million Royal Sussex hospital. That need for change, so that we have a better balance of specialty services, concentrated in specialty teams, underlines the need for change that has been recognised time and again.

The hon. Member for Holborn and St. Pancras showed a complete lack of understanding about the way in which health services are funded in London. I do not believe that it was a deliberate misreading of the information. I cannot believe that he saw the parliamentary answers to my hon. Friends the Members for Worcester (Mr. Luff) or for Croydon, North-East(Mr. Congdon). Let me make it clear. Health spending in inner London amounts to £553 per head —46 per cent. above the national average. Including the former special health authorities, spending per head in London is 56 per cent. above the norm. Inner London has more acute beds per person than the rest of the country, twice as many consultants and, as I have said, the costs are much higher—46 per cent. more to be treated in one of the teaching hospitals.

The amount of funding available for the health service will always be finite. The Labour party, which always promises the moon and delivers nothing, should be the first to know. My right hon. Friend the Prime Minister reminded the House of its deplorable catalogue when it was in power and responsible for the health service. We have to look to the way in which resources can most effectively be used. We do not resort to the constant denigration of people involved in health service management. To deliver change, support staff and plan buildings requires good management. Leading clinicians should be involved in clinical work. To denigrate one part of the service rather than the other is deplorable.

Mr. John Gorst (Hendon, North)

I fully understand the logic behind the medical and financial criteria to which my right hon. Friend is referring. However, where a closure is proposed—the proposal might not yet have come to her level, but consultation is taking place—if there are strong social reasons for keeping a hospital open, is it possible that she might overrule financial and medical grounds?

Mrs. Bottomley

In every case, careful consultation takes place, and has to take place. Certainly, it is not only narrow issues of value for money which weigh; it is looking for best value, best clinical outcomes and the interests of patients. Where a population feels very strongly about local provision, that must be strongly considered.

Mr. Toby Jessel (Twickenham)

My right hon. Friend earlier mentioned suburbs. As two thirds of London's population lives in outer London, did she notice that, although the hon. Member for Holborn and St. Pancras (Mr. Dobson), the Opposition spokesman on Transport, might know about transport, his sense of geography is a little odd, as he scarcely mentioned outer London at all, and practically the whole of his speech was on inner London? Is she aware that, in my constituency, there are four new GP surgeries, which people are very pleased with, and that people in outer London happen sometimes to fall ill as well and might need some service there, too?

Mrs. Bottomley

I thank my hon. Friend for making that point clearly. He does his homework and understands the situation in his constituency, unlike many other hon. Members.

There has been, rightly and properly, discussion of accident and emergency services. I suppose that a spokesman on transport could be allowed to have views that should be considered when it comes to ambulance services. He failed to remind the House, however, that this year we put an extra £14.8 million into the London ambulance service. That follows the figure of some £7 million for last year. The hon. Member for Holborn and St. Pancras is right to say that we have been far from satisfied by the performance that is being achieved by the London ambulance service. Indeed, my hon. Friend the Under-Secretary is, at this moment, with the London ambulance service, on a visit to one of its vehicles, but, unlike the Leader of the Opposition, he did not feel the need to summon up the television cameras to follow him on that visit. He regards it as part of his responsibilities to know what is going on. He does not feel that the visit would be wasted if he does not have a whole television crew pursuing him.

Not only has the extra money resulted in a new fleet with 120 more ambulances. Above all, when it comes to what our constituents need in accident and emergency services, we have gone from 300 to 400 paramedics since about the time of the last local elections in London. Having gone from 300 to 400, we are on line to reach 1,000 paramedics on those London ambulances by 1996.

Mr. Nigel Spearing (Newham, South)

Will the Secretary of State give way?

Mrs. Bottomley

Labour are, as ever, enthusiastic about their outrage but they are short on their analysis. Much of the pressure on accident and emergency departments is unnecessary and can be avoided. About half the patients using accident and emergency departments in London have minor injuries. They are not rushed in by an ambulance but walk in off the street, more often than not because the GP service locally needs to be better. I pay tribute to all those nurse-led minor-injury facilities such as the one at St. Charles's hospital which provides excellent, high-quality care and relieves the pressure on local emergency services. Similarly, I welcome all those—

Mr. Spearing

On a point of order, Mr. Deputy Speaker. You may have understood an oral request to the Secretary of State, but as she is so engrossed in her copious notes, I do not know whether she is—

Mr. Deputy Speaker

Order. The hon. Gentleman knows that that is not a point of order.

Mr. Spearing

Will the Secretary of State give way?

Mrs. Bottomley

I have had frequent lengthy discussions with the hon. Gentleman, not least on the Thames and on other occasions. I have learnt from experience that if he wishes to make his point, it is wise to let him make it in his own speech if he catches your eye later, Mr. Deputy Speaker.

The right thing to do is take a considered view of the development of accident and emergency services in London. The London implementation group is advised by Professor Norman Brouse, the president of the Royal College of Surgeons, with a team of experts on accident and emergency services. The Chief Medical Officer is advised by Professor Howard Baderman whom I believe works in the Holborn and St. Pancras constituency.

Mr. Dobson

He does a very fine job, too.

Mrs. Bottomley

I am pleased to hear that he does a fine job. In that case, I suggest that the next time the hon. Gentleman sees him, he listens rather than speaks, and remembers that he has two ears and one mouth because what he will hear from Professor Howard Baderman is that accident and emergency services need to be concentrated in centres of excellence with a back-up facility. The problem at Bart's is that it has such a small accident and emergency unit because the population has so substantially reduced that it becomes ever less viable as a full accident and emergency service. That is the full thinking behind the Government's decisions on the development of services in London.

What discourages me about Labour is its inability ever to look constructively and analytically. Do we ever hear from the hon. Member for Peckham (Ms Harman) or, indeed, the hon. Member for Dulwich (Ms Jowell) about the £8 million being spent on the accident and emergency department at King's College hospital? Do we ever hear about the £40 million to provide 10 new operating theatres and extra intensive care at King's College hospital? Do we ever hear that in the House?

Mr.Dobson

rose—

Mr.Deputy Speaker

Order. Let us have a bit of order on the Labour Front Bench. [Interruption.] Order. The Secretary of State has made it clear that she is not giving way.

Mr.Dobson

On a point of order, Mr. Deputy Speaker. Is it orderly for the Secretary of State to challenge my hon. Friend the Member for Dulwich (Ms Jowell) to be here and say something when she has just come out of hospital and is at home? She would like to be here but she cannot.

Mr. Deputy Speaker

The Secretary of State will answer for herself.

Mrs. Bottomley

The hon. Member for Dulwich, like the hon. Member for Peckham, is swift to embark on a catalogue of often vindictive criticism with a disregard for the facts. Labour is so lamentably slow ever to praise a hospital which is a good hospital and which stands to benefit greatly from the changes in London. Not only King's College hospital but Maudsley hospital stand to benefit from the move of the neurosciences to become a worldwide centre of excellence in neurosciences. However, that is something that Labour Members never mention because it does not suit them, even though it is a substantial investment in their own constituencies, directly benefiting their members.

Similarly, the hon. Member for Lewisham, East (Mrs. Prentice) does not mention the £4.3 million spent on the accident and emergency department and the £23 million development with 200 new beds, two new wards and a new children's unit. How many of my hon. Friends know about the developments of the Lewisham hospitals, which Labour so lamentably fail to recognise? Mr. Deputy Speaker, I know that my hon. Friends will want to catch your eye later so they can tell us about the excellence of those services and developments.

Perhaps even more important, I am disappointed that the hon. Members for Hackney, South and Shoreditch(Mr. Sedgemore) and for Hackney, North and Stoke Newington (Ms Abbott) have failed to join us today. It is sad that when £25 million is being spent at the Homerton hospital—

Mr. D. N. Campbell-Savours (Workington)

On a point of order, Mr. Deputy Speaker. May I set the record straight? My hon. Friend the Member for Hackney, South and Shoreditch (Mr. Sedgemore) has been here for the whole debate and has just gone to that hospital.

Mr. Jeremy Corbyn (Islington, North)

Further to that point of order, Mr. Deputy Speaker. My hon. Friend the Member for Hackney, North and Stoke Newington (Ms Abbott) is on an official delegation to South Africa to monitor the elections there. It should therefore be at least clear—

Mr. Deputy Speaker

Order. We now have that on the record.

Mrs. Bottomley

The point is that the constituency of the hon. Member for Hackney,North and Stoke Newington stands to benefit greatly from the enormous investment in Homerton hospital. I appreciate that the hon. Member for Hackney, South and Shoreditch was here, but he has left the Chamber and has no intention of saying that the beneficiaries of the changes are not the 4,000 resident population of the City but the 190,000 people who live in Hackney. It is when Labour Members—

Mr. Campbell-Savours

On a point of order, Mr. Deputy Speaker. Once again, the Secretary of State forgets. My hon. Friend the Member for Hackney, South and Shoreditch has gone to a meeting with all the staff at Bart's, which I understand will last for four hours.

Mr. Deputy Speaker

Order.

Mrs. Bottomley

I shall repeat the point.

Mr.Gorst

On a point of order, Mr. Deputy Speaker. May I ask you to make it clear that Labour's pairing arrangements have absolutely no part in our proceedings at present?

Mr. Deputy Speaker

Order. The debate is not about Labour's pairing arrangements.

Mr. Andrew Mackinlay (Thurrock)

On a point of order, Mr. Deputy Speaker—[Interruption.]

Mr. Deputy Speaker

Order. I have listened to several points of order now. I hope that the hon. Gentleman's point of order is a genuine one. If it is not, I shall take a dim view of it.

Mr. Mackinlay

Oh dear. In that case, I shall sit down.

Mrs. Bottomley

I understand why Labour are so uncomfortable. Their betrayal of the achievements of the health service always corners them. I have visited Homerton hospital.

Mr. Sedgemore

On a point of order, Mr. Deputy Speaker. [Interruption.]

Mr. Deputy Speaker

Order. The House should settle down. If hon. Members stop behaving like schoolchildren, we might be able to get on with the debate.

Mr. Sedgemore

Mr. Deputy Speaker—

Mr. Deputy Speaker

As I said to the hon. Member for Thurrock (Mr. Mackinlay) before the hon. Gentleman entered the Chamber, I hope that it is a genuine point of order.

Mr. Sedgemore

I apologise for leaving the debate as I am going over to St. Bartholomew's hospital.

Mr. Deputy Speaker

The hon. Gentleman's apology is accepted.

Mrs. Bottomley

I hope that the hon. Gentleman will not leave immediately because I shall repeat what a tremendous service Homerton hospital will be providing for the 190,000 people who live in Hackney, rather than the 4,000 people who live in the City, albeit that there is an important visiting population who work there. About £25 million is going to the Homerton hospital—more than £1 million of it is going to accident and emergency services. I am delighted to have the attention of the hon. Member for Hackney, South and Shoreditch because I know that he wants to know more about the 26-bed admission ward, the two new acute wards, the new paediatric and outpatient blocks, the CTMRI—computerised tomography magnetic resonance imaging—scanner, the radiology unit, the new pharmacy and the expansion of the special care baby unit.

When I visited Homerton hospital late at night shortly before Christmas, people there were only too pleased that we had taken the principled view that investment should go where the people are. People should not have to travel to buildings; we should take services to the people.

Bart's has developed great excellence, which will be strengthened and consolidated by its merger with the new trust, which is to be made up of Bart's and the Royal London hospital. When one talks to the people involved in the work, who look outward and are involved in developing primary care, one finds that that expertise and those traditions, which go back many centuries, will continue to benefit patients and staff for many generations.

Mr.Tracey

I must underline the excellent argument of my hon. Friend the Member for Twickenham (Mr. Jessel). If the people of Hackney and other parts of inner London are ungrateful for the vast extra resources that my right hon. Friend is describing, perhaps she should put those resources in the outer London boroughs of Richmond, Kingston, Croydon, Enfield, Brent, Harrow and Redbridge, where we will thank her for them.

Mrs. Bottomley

My hon. Friend tempts me, because allocating resources in a principled way is an unrewarding pursuit when it comes to the Opposition.

On the same lines, we heard nothing from the hon. Member for Holborn and St. Pancras about the Government's commitment to University College hospital in his constituency, which has been given £10 million in transitional funding. I am afraid that that money cannot be spent in the constituency of my hon. Friend the Member for Surbiton (Mr. Tracey) or in that of any of my other hon. Friends. That hospital will rightly remain a great world centre of teaching, research and treatment.

Did we hear about the 92 primary health care projects, the £12 million being spent in Camden and Islington in the first two years, the Brunswick square and Hunter street developments and the work in the King's Cross area to help homeless people or the local Bangladeshi population? Did we hear about the Crowndale development for general practitioners there, or about their new practice nurses—the number of practice nurses has increased by three times. We did not hear about any of those great achievements or the programme of changes that are under way in the health service in London.

All hon. Members are right to be concerned when things go wrong. The hon. Member for Holborn and St. Pancras asked about the people who provide information in the national health service. It is a very large organisation and it is important to have information available. Last week, we heard about the tragedy involving children in a Manchester hospital. People at the centre need to know swiftly and urgently about the state of affairs.

When something goes wrong at an accident and emergency unit, urgent action needs to be taken. I made it clear much earlier this year—when we were worried about unacceptable trolley waits—that NHS management is to improve and that managers must ensure that patients are admitted to, or discharged from, hospital more effectively.

Do the Opposition understand that we can relieve pressure on accident and emergency departments by investing in primary care? Above all, do they criticise local authorities, whose failure to agree proper discharge arrangements with hospitals so often leads to patients staying longer than necessary in hospital? Patients in accident and emergency departments have to wait for beds as a result.

Are the Opposition aware of the fact that when we last had problems at King's College hospital 40 patients were waiting to be discharged? Perhaps they could help me to encourage the local authorities of Lambeth and Southwark to use the extra money that they get for community care to fulfil their commitments to make effective discharge arrangements. The Opposition should concentrate more on that subject in their pre-local election gimmick run.

In London this year, an extra £135 million will be available for community care—77 per cent. above the level of grant last year. I do not recall—I do not know whether my hon. Friends do—the hon. Member for Holborn and St. Pancras mentioning that Camden has had a 100 per cent. increase—£5.3 million—for community care this year. I wonder whether any of my hon. Friends did. [HoN. MEMBERS: "No."] Did my hon. Friends hear about the extra £5 million for community care in Greenwich? Did they hear about the £5.4 million for Hackney, the £6 million for Lambeth and the £6 million for Southwark? Did my hon. Friend the Under-Secretary of State hear about the £6.5 million for Wandsworth? The Opposition should be ensuring that Labour-controlled councils provide the services that they should be providing and that they do so more thoroughly and vigilantly.

All too often, it is Labour's neglect that builds up the pressures on our emergency services. Today, the King's Fund produced another report on the state of the health services in London. The hon. Member for Holborn and St. Pancras mentioned one report, but it is hardly worth explaining to him how he misunderstood it. Well over £2 billion is spent on the health service in London. The King's Fund report endorsed the need to spend money on community and not acute services—albeit that the report was discussing how the weighted capitation system works. The report, "Giving Voice to Londoners," is perhaps even more important and I am sure that the Opposition would have quoted if it had suited their partisan needs. It said that Londoners want a combination of well-resourced central hospitals, centres of excellence, more primary care offering minor surgery, specialist clinics, social care and community support. Those are also our policies and they are the right policies.

By pursuing the programme of strategic change that we have put in hand, we shall be able to put an end to uncertainty, and uncertainty is very hard for people working in the health service in London. We shall be able to realise that vision for the health service in London which is set out in the King's Fund report. Baroness Hollis, the noble Friend of the hon. Member for Holborn and St. Pancras, supported that report. Perhaps when he has compared notes with his party's spokesman on health, he may wish to go for further advice to Baroness Hollis, who played such an important part in presenting the original case.

As the independent specialty reviews last summer recognised, centres of excellence are created by bringing specialist services together and linking them to other hospital care. That is the expert medical view and the view that underpins our approach. We have honoured our commitment to protect the excellence of London's medical research, by providing generous funding for the special health authorities to support their research as they make the transition to trust status.

The hon. Member for Holborn and St. Pancras rightly referred to the Marsden, Brompton and Great Ormond Street hospitals—those special health authorities of such great standing. They have been very warmly funded. We have been able to bring the medical schools together successfully with the multi-faculty colleges. The hon. Gentleman's motion referred to education, so I was surprised that he failed to recognise the great significance of medical schools becoming part of a wider team with postgraduate centres and the broader scientific base. If we want to continue to have world-renowned doctors, that is an important step forward. That is why, when we propose to concentrate services, we also want to release further investment in research and education. It is not that we will lose some excellent teams. The point is that they will be moved to an environment that better supports their work and improves services for patients. That involves upheaval during the change, but that is not a reason why we should lose those teams or why they should not continue to grow and prosper in a different setting.

Far from destroying centres of excellence, our policies are designed to create, enhance and strengthen them. Indeed, every hospital that the hon. Gentleman mentioned will be combining with other teams. Those hospitals will be stronger, more effective and better able to engage in research and teaching. At the same time, we shall continue to give Londoners the better primary care that they want. That is why we have unleashed a formidable programme of investment to improve premises, build new community services, provide more and better-trained doctors and nurses working in the community and target the vulnerable groups, such as the elderly and mentally ill, who most need that community-based help.

This year, investment in London's primary care has doubled, amounting to more than £85 million. Well over 700 projects are under way, contributing to arrangements in a variety of services.

An Hon. Member

It is all waffle.

Mrs. Bottomley

I find it extraordinary that an hon. Gentleman should mutter "It is all waffle" under his breath. As I have said, 700 projects are under way, all detailed and documented. In my view, that constitutes a clear and substantial investment in change. The amount exceeds what we were asked to provide either by Professor Tomlinson or in the King's Fund report.

We have always been clear about the fact that we could bring about change only when we were able to make such an investment in primary care, and could be sure that change would lead to improvements and a better balance of services. Londoners hear nothing about that from London Labour Members.

Mr. Nick Raynsford (Greenwich)

Will the Secretary of State give way?

Mrs. Bottomley

I think that I have given way very much more than the hon. Member for Holborn and St. Pancras. A number of my hon. Friends were desperate to intervene in his speech. I pity him, because his sudden ascension to his current brief must have made it difficult for him to give way. I have tried very hard to be patient with Labour Members, but I am worried about cutting into the time of my hon. Friends.

Mr. Raynsford

On a point of order, Mr. Deputy Speaker. Is it in order for the Secretary of State to complain that she has not heard from Greenwich—as she did earlier —when she has repeatedly refused to give way to me on points directly related to her speech?

Mr. Deputy Speaker

The Secretary of State's speech is clearly in order; otherwise the Chair would have ruled it out of order.

Mrs. Bottomley

I have offered Labour Members an agenda, Mr. Deputy Speaker, suggesting some items that they might wish to raise if they are fortunate enough to catch your eye. I thought it only fair that, in the unlikely event of their again failing to recognise the great achievements of the health service and what is happening in their own constituencies, London residents should hear about some of the major investment that is taking place in the capital. I believe that, as this great raft of investment and projects becomes ever more public and visible, the Labour party's distorted, one-sided picture of the NHS in London will be exposed for what it is.

In 1992, the King's Fund report pointed to the need for fundamental change in London's health service, stating: Action is needed to safeguard London's proud tradition of healthcare and medical education, and to forge new patterns of healthcare, medical education and research to meet Londoners' requirements in a new century. Commenting on what were radical recommendations in the King's Fund report to reduce hospital provision, one newspaper said: Paradoxically those recommendations could well help ordinary Londoners if the money spent on specialist services were diverted to basic medical care".

Mr. D. N. Campbell-Savours

It was the Evening Standard.

Mrs. Bottomley

The hon. Gentleman is right: paradoxically—again—that newspaper was the Evening Standard. Many others made the same point, however. The Guardian said: only the ideologically blind are refusing to recognise the truths set out in the King's Fund Report that has rightly concluded that the present surplus cannot continue. The Independent said: Change cannot be avoided. London's hospitals have been absorbing too high a share of NHS resources at the expense of hospitals elsewhere and of primary care standards in the Capital. The balance must be addressed. Sentiments aside, it is the patients who will gain".

Mr. John Austin-Walker (Woolwich)

On a point of order, Mr. Deputy Speaker. I fear that the Secretary of State may be in danger of misleading the House by quoting the King's Fund Research Institute, given that it has published another document more recently. In that document, produced in April 1994, it states that it may have been wrong—

Mr. Deputy Speaker

Order. That is not a point of order; it is a matter for the Secretary of State.

Mrs. Bottomley

The hon. Gentleman has failed to understand the significance of the King's Fund report. I suggest that he, too, should consult Baroness Hollis, who will be able to speak at length on the matter. He might also wish to read the remarks of Robert Maxwell, head of the King's Fund: only this week, he again spoke of the need for change and commended the progress that we are making.

The Times said: The structure of health care in the Capital is archaic". The medical profession as a whole has been equally supportive. According to Paddy Ross, chairman of the Joint Consultants Committee, As a result of meaningful consultations, ministers produced a Government response to the Tomlinson Report the broad thrust of which is supported by the medical profession at national level". Professor Chris Ham—who is, I believe, respected by hon. Members in all parties for his knowledge of health matters —said: 'The reality is that there is no alternative to a radical re-shaping of London's health services and only those out of touch with the direction of health policy would have believed otherwise". He continued: Sentiment and political lobbying should not stand in the way of a restructuring that most independent commentators would argue is long overdue". These changes are indeed long overdue. Professor Ham was right, the King's Fund was right and 20 reports in the past 100 years have been right. All that Labour says, however, is that there should be a moratorium, and that a further inquiry and report should be delayed. Even the hon. Member for Brightside was right when he said that the status quo in London was not an option; it is a sign of the Labour party's hypocrisy that he has been written out of the script for uttering such politically incorrect views.

Labour has turned its back on that wide consensus today because it puts its own short-term interests above those of the NHS, and above those of patients. Next week's elections in London are not about the NHS; they are about social services—[Interruption.] Labour Members clearly wish to divert attention from the record of their own authorities on social services, schools, roads—

Dame Elaine Kellett-Bowman

Housing.

Mrs. Bottomley

And on housing. I am not surprised: the so-called care workers of councils such as Lambeth bully the elderly and mentally ill in their care, while councils such as Islington allow the children under their protection to be exploited by pimps and paedophiles. In contrast, there are councils such as Kensington and Chelsea, which has advanced one of the most forward-looking health strategies in partnership with its local health authority. I was able to visit it last week. Such councils are responsible for the services that they provide, and act as good stewards of their local communities.

Where Labour is in power, it fails the vulnerable and deserts the sick. I need hardly remind the House that when it was in power nationally, it was the Confederation of Health Service Employees shop steward at the hospital gate who decided which patient was treated and which patients were not: if Labour Members are reluctant to remind the public of that, my hon. Friends will do so.

Once again, we have heard denigrating remarks about accountants. Only Labour believes that a health service can spend more than £100 million a day without needing good accountants. It is one of the largest, most complex organisations, providing vital services; it needs good, effective managers and accountants. That is why we owe so much to Sir Roy Griffiths and his report on management in the health service. [Interruption.] Labour Members interrupt most when they are least comfortable with my remarks.

I was speaking of the COHSE official at the gate deciding whether or not patients should be treated. This was an NHS run by thugs with a union rule book in one pocket and a Labour Government in the other. Now, in opposition, the Labour party cynically manipulates the health service for its own narrow partisan purposes.

Conservative Members remember the last general election, which the hon. Member for Livingston unwisely said would be a referendum on the NHS. We have not forgotten the disgrace of Jennifer's ear, and nor have the public. Labour's scare tactics then earned it contempt and lost it votes: when Londoners come to judge next week, let them show their contempt for Labour once again.

5.39 pm

Mr. Simon Hughes (Southwark and Bermondsey)

I declare my interest, which the Secretary of State and the Minister well know. I am the Member of Parliament for Guy's hospital and, because of that, I have a somewhat front-line position in the debate about the future of the health service in London.

Like all London Members, I have constituents who use other London hospitals and other parts of London's health service. I certainly have constituents who are patients at St. Thomas's, and constituents who use King's, Bart's and many others. Why do they go other than to their local hospital? It is possibly because those are the best hospitals, and the London health service has some of the best health care in the world.

The background to the debate today may be divided into four significant considerations. The first was repeated in the more recent King's Fund reports, which have been alluded to today. A section in the King's Fund report has just been produced entitled, "Public Opinion" and a subsection called "Comparing dissatisfaction," which reads as follows: The King's Fund Institute has collected and analysed national survey data on the views held by Londoners and by people in the rest of the country concerning the NHS and constituent services…Londoners are consistently more dissatisfied with all aspects of their health services than people living in comparable metropolitan areas in the rest of England. I remember when the senior nursing officer at Guy's came from Aberdeen. At the first meeting I had with her, she said that people in Aberdeen would not put up with the conditions of the health service in London and that the services in Aberdeen were considerably better. The purpose of today's debate is to try to bring about an understanding that there will be continuing dissatisfaction about the health service in London until the health care provided in our capital city is of the standard that it is in many other parts of the United Kingdom.

The second background point to today's debate is that 83 per cent. of people in the most recent opinion poll which I saw believe that there should be more money spent on the health service. Considerable numbers of people—more than 40 per cent.—said in the same poll that they were willing that 5p in the pound extra be spent. The opinion poll's support for the health service contrasts markedly with the lack of support in London for the Government.

It is a telling fact that, whereas at the general election the Conservative party's support in London was much higher than its average support throughout the country, the Conservative party's support now is much lower in London on average than in the rest of the country. That is not saying much, as the average in the rest of the country has come down, but more support has been lost in London than elsewhere.

The third obvious point is that the debate is all about the implementation of the health service reforms and the Tomlinson report.

The fourth point, about which the Secretary of State made a great song and dance, is that we are having the debate in the run-up to the London borough elections. If the right hon. Lady thinks that health is not an issue in the London borough elections, I do not know where she has been or to whom she has been listening.

Mr. Dobson

The accountants.

Mr. Hughes

Certainly it must be to people who never go out of their doors and talk to voters.

Voters determine the issues, not political parties, and the voters of London realise that local authorities have responsibility for social services but not for health services. They also realise that the way in which the health service is run has a direct impact on what local authorities can and ought to do. Many of the voters in London are extremely unhappy about the Government's proposals for the health service.

I should add a postscript lest it be thought that this is an inner London concern and not an outer London concern. An article—not written by politicians—appeared recently in a local newspaper in Kingston upon Thames entitled, "Ward Furore." The article discussed a subject of acute controversy in Kingston, which was reported as follows: Kingston Hospital is converting an empty ward into an exclusive unit for private patients and building a private operating theatre…The new private facilities may be paid for by the taxpayer…The hospital has had private patients since 1948, but the new unit and operating theatre will be the first exclusively for private use. At present, private and NHS patients use the same facilities. It is not just in inner London, but in other parts of London that there is considerable voter dissatisfaction with the Government's proposals for the health service.

Mr. Nigel Forman (Carshalton and Wallington)

The hon. Gentleman mentions the part that health is playing in the local elections. Will he take this opportunity to condemn unequivocally the action of his Liberal colleagues in the London borough of Sutton, where there are local elections, who are cynically scaremongering about the future of the excellent St. Helier hospital in my constituency?

My constituency also benefits from an even more well-known renal unit which covers the whole region. Both those excellent units are enjoyed by people from neighbouring constituencies, who have been scared witless by Liberal propaganda suggesting that the hospital is likely to close. Will the hon. Gentleman take this opportunity to condemn that cynical scaremongering?

Mr. Hughes

I happened to go to the Sutton civic offices today, and I have not seen any such scaremongering. The local authority in Sutton, which my colleagues run, has provided a direct bus service from St. Helier hospital—I went on the bus on the day the service was inaugurated—through the more deprived parts of Sutton into the middle of the borough. I do not think that such a policy is consistent with a belief that the hospital is about to close.

There is great concern in Sutton—as in Kingston and other boroughs, such as mine in Southwark—that the Government's policy towards the health service will not achieve the levels of resources which inner and outer London need.

Mr. Forman

rose—

Mr. Hughes

In answer to the hon. Gentleman's question, I will inquire. If the matter is an election issue in Sutton, it is because the voters of Sutton want the health service to continue with maximum resources, and not to be at risk.

Mr. Spearing

Would not the problems that we have had in the past exchanges be solved if the Government took account of the latest King's Fund report, and not the reports to which the Secretary of State referred? The latest King's Fund report says: However, adjusting the balance between hospital and community-based care will take time. New services must be put in place before old ones are declared redundant. If the Government would take the advice of that report, the situation that has just been described would not be relevant.

Mr. Hughes

rose—

Mr. Deputy Speaker

Order. Before the hon. Gentleman attempts to answer, let me say that there have been two interventions since he began speaking and both have been lengthy. [Interruption.] Order. Many hon. Members are hoping to catch the Chair's eye before the debate finishes. If we continue to have long interventions of that nature, some will be unsuccessful.

Mr. Hughes

For that reason, I shall not give way unless there are exceptional circumstances. I know that a lot of hon. Members want to speak.

Lady Olga Maitland (Sutton and Cheam)

Will the hon. Gentleman give way?

Mr. Hughes

No. The hon. Lady represents the same borough as the hon. Member for Carshalton and Wallington (Mr. Forman). I have dealt with the Sutton point.

Lady Olga Maitland

rose—

Mr. Hughes

No, I shall not give way.

The voters, the people and the patients of London are so concerned because when the service is examined it is often found to be significantly wanting. A check on conditions in the acute sector of hospitals was carried out on 25 April. On that day, 58 Londoners faced delays of more than three hours in casualty wards while eight hospitals had clamped down on emergency admissions.

Hon. Members who represent London constituencies know that many people who need health care in London —usually because they live here, but sometimes because they work in London or are visiting—often cannot obtain that care in the way the NHS was intended to provide it. For as long as the remains the case, the Government must be much more careful about how they introduce changes in the health service.

The problem is that Londoners simply do not believe the Government. I will give the Secretary of State an obvious local example. She knows in advance what I am about to say. At the end of the 1970s and the beginning of the 1980s, a small cottage-type hospital in my constituency serving people from Southwark and Lewisham, St. Olave's, was closed with the promise that the services would be preserved at Guy's. It is now clear that that will not happen if the Government's proposals go ahead because normal in-patient treatment will not be available under the reforms proposed at Guy's. It is not surprising that people do not believe the Secretary of State when promises made under one Administration are dishonoured under the next.

Mr. Tracey

Will the hon. Gentleman give way?

Mr. Hughes

No, I shall not give way.

The fundamental problem of the reforms in the health service is that they are being carried out without the assent and approval of the people most affected. If a Government who were elected on a minority of the vote in the country and in the capital city are determined to go ahead with extremely controversial reforms and set up a structure whereby all the health authorities are appointed exclusively by the Government, and then set up a structure whereby the providers are made into hospital trusts, all of which are appointed by the Secretary of State and their decisions taken in secret, it is not surprising that the people of London do not trust the management of the health service.

The health service employs many excellent people, including good administrators, but it is no longer an accountable service. It is accountable only to the Secretary of State, who neither listens nor hears. If she did, she would not go in the direction in which she is going and she would not lose the argument. Her speech today was a classic illustration. She spent five minutes discussing why the hon. Member for Holborn and St. Pancras (Mr. Dobson) had spoken. That was not of huge interest to the people of London, important though it may be to the Secretary of State. She should have tried to win the case instead of making party political points. The Labour party has, perfectly properly, used a day allocated to it to discuss a subject of huge interest not just to the Labour party but to all parties in London.

Mr. Tracey

Will the hon. Gentleman give way?

Mr. Hughes

Perhaps I should make an exception and give way to the hon. Gentleman as he, too, represents a Kingston constituency. Next week, the Tories may lose that borough to us, so this may be the last time he can stand up and say that Kingston council is Conservative controlled.

I beseech the Secretary of State to listen. I will explain why the London case is being handled so wrongly and what she needs to do. Exceptionally, I shall give way to the leader of the Conservative group of London Members of Parliament so that he can have his swan song before a substantial Conservative defeat in London next week.

Mr.Tracey

I am sorry to disabuse the hon. Gentleman. He may be a little surprised next Thursday when the leader of the Liberal Democrat group in Kingston council loses his ward.

On a more serious point, the hon. Gentleman has been putting forward what he believes is a rationalised, plausible whinge to the House. I have before me a map from the London initiative zone showing the capital schemes commencing in 1993–94. In the hon. Gentleman's area of Southwark, together with Lambeth and Lewisham, there is a mass of capital schemes. The hon. Gentleman goes on about Guy's and St. Thomas's, where the clinicians have said that duplication was making clinical services inefficient. Does he deny that vast numbers of capital schemes are coming on stream in Southwark, Lambeth and Lewisham?

Mr.Hughes

It was not worth giving way to the hon. Gentleman. The answer is no, of course I shall not deny it. I have always given credit where it is due. The health needs of London are such that a huge amount of resources are still needed, for reasons which I shall briefly elaborate in a moment. If the Government listened to the needs of the users of the service, they would realise that running down loved and favoured centres of excellence with established teams of experts, which attract people from all over the country and the world, is not the way to develop the health service in the capital city.

A section at the beginning of the Tomlinson report sets out the health needs of London. It makes the clear case that, first, a huge number of people, other than those who live here, come to London for treatment; secondly, London has more under-privileged areas than anywhere else in the country; thirdly, London has a more diverse population needing more special health care than elsewhere in the country. It goes on to elaborate on the number of homeless people, the standardised mortality rates and the people with special needs, such as HIV and AIDS patients.

The Secretary of State did not concede entirely the point that I put to her in an intervention—that it is the same throughout the public service in London. It is never an argument to say that we can run down the amount of money spent here and distribute it in the rest of the country if the consequence is that we do not have the funding to meet the higher costs of providing the service here. Neither my hon. Friend the Member for Rochdale (Ms Lynne), who speaks for the Liberal Democrats on health and represents a northern constituency, nor I have never argued that the Government should not develop the health service elsewhere. I put it on the record that, like the hon. Member for Holborn and St. Pancras, we have never argued that there should not be rationalisation in London. It is not logical to have four units dealing with the same specialty in four neighbouring hospitals if they can be concentrated in one.

We have consistently argued for a rational provision across London, but it must take account of factors such as the difficulty of travel, the number of people without cars, and the time it takes to cross London, which is often congested with traffic. It must take account of the fact that once a team of experts is destroyed, it cannot be built up again. It must take account of the fact that, whatever the Secretary of State may wish to do, people will always be referred to top specialists who happen to be based in top London hospitals and those people will come from elsewhere in the country and from abroad.

It is no solution to tell people in London that their hospital sites at Guy's, St. Thomas's, King's or Lewisham happen to be too expensive because of the cost of land, so the purchasing authority for the south-east London health authority must buy a cheaper service and people will have to go to Brighton to receive the care. That is not what the health service is supposed to be about, but it is the danger of the Government's policies. As the advertisements on hoardings in London say, the service is so run by accountants and fundholders that everything is determined by cost rather than care. [HoN. MEMBERS: "Not true."] It is true. Ultimately, services are no longer provided, because health authorities are told that they have no more money. It is true that the purchasers choose where to buy the service. They will close a service—just as they have closed the ophthalmology unit at Guy's hospital so that patients are now treated at St. Thomas's—because that is how they believe that they will get best value for money, but it may not be the best place for the patient, as it may not be near where he lives or convenient for him to travel to. As the patient no longer has any direct say in the health authority, decisions are taken that run increasingly away from the needs of the London community.

Mr. David Congdon (Croydon, North-East)

Will the hon. Gentleman give way?

Mr. Hughes

I am sorry, but I shall not give way.

One bugbear is the fact that the Government have claimed great successes which have been fictional. I am delighted that this month the Government have announced that waiting times are to be be measured not from when the patient sees the consultant until when he or she is treated, but from the time a patient visits the doctor until he or she is treated. For the clock to be ticking only from the time one saw the consultant meant that, for many people, it was a year before the clock started to tick. I hope that we shall be honest about the assessment of waiting times. My constituents regularly come to me and say that they have been waiting for years, certainly for months, to be seen or treated. The same is true of constituents throughout the capital city. The test of the efficiency of the health service in delivering care to patients lies in the length of time taken between the need arising and the need being treated.

I come now to the subject of greatest concern to me and my constituents. Ministers still think that the case being put for keeping in-patient beds and an accident and emergency department of some sort at Guy's hospital is being put by consultants. The consultants may be making a case and they have an interest, but they also have a concern and if Ministers think that their battle is with the consultants and that it is the consultants whom they need to head off, they are fundamentally wrong. It is not the consultants who are most concerned about the rundown of services planned for Guy's hospital, but the people who work in and use the health service.

Our case is simple. We do not argue that there should be duplication. We do not argue that Guy's should stay open and Lewisham, King's or St. Thomas's close. That is definitely not our argument. We argue that, according to the Jarman scores, south London is under-resourced in terms of beds when compared with the rest of the capital city. When we consider the patients' needs, it is no good thinking about closing the accident and emergency department at one hospital unless it has been proved that there is spare capacity elsewhere. Above all, if the Government think that they can go on arguing that one hospital serving a catchment area and patients from much further afield can be closed without damaging Londoners' health care and putting their lives at risk, as well as a damaging the Government's reputation, they are sorely misguided.

I have always sought to be rational when putting the case for the health needs of my constituents in the capital city. My colleagues and I have always sought to be reasonable and have recognised that the health service is not a bottomless pit. But we want the Government to accept that there is still a good case for keeping the four hospitals in the south-east London health authority area and not taking out a hospital when such acute need is constantly and clearly not being met.

Ms Kate Hoey (Vauxhall)

Is the hon. Gentleman aware that there is much concern in parts of my district of Lambeth and parts of Southwark that some of the propaganda material—good material—distributed by the "Save Guy's" campaign has been seen by some people as a campaign to close St. Thomas's hospital, not to save Guy's. It is important to state that that is not what is being put out. Will the hon. Gentleman give a firm commitment that the "Save Guy's" campaign is not about closing St. Thomas's hospital, as some of the denigrating literature that has been circulating has been extremely badly received by people working at St. Thomas's who care very much about that hospital?

Mr.Hughes

I was not intending to give way, but I am happy to deal with the hon. Lady's intervention. I can expressly say to the hon. Lady, whom I respect and value as a colleague, although she is not in my party, that nobody involved in the campaign to keep Guy's open as an in-patient hospital and an accident and emergency hospital wants any reduction of services at St. Thomas's, King's or Lewisham. We believe that the figures, the evidence and the arguments advanced to Ministers show that there is a case for all the hospitals to remain without duplication and in a complementary way. Now that the initial misunderstanding is out of the way, I believe that increasing numbers of people at St. Thomas's—staff nurses, administrative staff and consultants—will realise that we must stand together or risk not standing at all.

The Minister for Health (Dr. Brian Mawhinney)

I have listened carefully to the hon. Gentleman's answer to the hon. Member for Vauxhall (Ms Hoey). We must clarify the position a little further. It is a matter of public record that when I conducted consultation exercises at Guy's and at St. Thomas's, the consultants on both sides said that their overriding desire was for a single, acute hospital site. Each side said that they would like it to be on their site, but when specifically asked by me whether they wanted to retain the services on their site or on a single site, the consultants on both sides said that for clinical coherence they attached greater significance to a single site. As both hon. Members know, this year we are investing £18 million into the Guy's and St. Thomas's trust to enable it to function. That is extra money which will not be available to anyone else in the health service. In the light of the experience that I have just related, does the hon. Gentleman believe that we should keep spending more each year—on top of the £18 million and on a rising curve, as it would be—in order to maintain the clinical incoherence that he advocates?

Mr.Hughes

I am happy to answer that. The Minister knows that I want us to have a rational debate on agreed facts and figures. If we could consult on the facts and figures that led to the strategic decision announced in the House on 10 February by the Secretary of State, we would realise that there is no logic in the Government's conclusion. The logic of the Government's decision contains various anomalies, such as the Philip Harris house anomaly. A building was built for £140 million and it was then announced that it was not to be used for its intended purpose. It was also anomalous to open an accident and emergency extension on the very day it was recommended that it should be run down. There was an anomaly in the fact that people were asked to give money for a new building for a specific purpose. When it was announced that the building was not to go ahead, the people said that they wanted their money back, which increased the bill for taxpayers.

If the Government are willing to sit down with the people at St. Thomas's and Guy's, the local community, the community health council and people who care, including Conservative and Opposition Members, we can win the argument to show that the facts and figures—the cost benefit to the Government and to the taxpayer—show that it is better to keep fully functioning hospitals on both sites. If the Minister will let us put the case, we believe that we can persuade him of it. My hon. Friend the Member for Rochdale, who speaks on health matters for the Liberal Democrats, and I have only ever asked that the Government's health service reforms should be the subject of consultation and should be based on agreed facts and figures. If the Government do that, their popularity may increase, but if they continue with their present policies I predict that the Government, as well as the patients who need the health service in London, will be the losers.

6.8 pm

Mrs. Marion Roe (Broxbourne)

Thank you, Mr. Deputy Speaker, for giving me the opportunity to speak early in the debate.

The Select Committee on Health, of which I am Chairman, has taken a keen interest in the national health service provided in London, with particular emphasis on the Tomlinson report. As my right hon. Friend the Secretary of State explained earlier, over the years, 19 reports on the future of health care in London have been produced. The Tomlinson report was the 20th such report. The Health Select Committee decided that it would not produce report No. 21, but would instead keep a watching brief on the issue. However, I am certain that everyone will agree that the Tomlinson report was necessary, and some will claim overdue.

As my right hon. Friend the Secretary of State said earlier, even the Opposition Front-Bench spokesman, the hon. Member for Sheffield, Brightside (Mr. Blunkett), admitted that the "status quo is no longer an option". Ministers need a great deal of courage to take the essential decisions, some of which are likely to be unpopular. I congratulate my right hon. Friend and her ministerial colleagues on grasping the nettle, because it had to be done.

In order to put the debate into perspective, I think that we should remember that the population of inner London requiring health services has changed dramatically over the years. In 1901, the population of inner London was 4,533,000. In 1991, the population of inner London was 2,080,000—more than a 50 per cent. decrease. One million people have left London in the past 30 years. Many former Londoners have moved into the home counties and beyond, some of them settling in my constituency in Hertfordshire, and they are looking for high-quality national health services where they live now, not where they used to live.

In recent years, there has been conflict over the distribution of funds within the NHS London regions, the bone of contention being equity between inner London on the one hand, and outer London and the home counties on the other. It has always been claimed that too large a slice of the cake was being taken for central London hospitals and not enough was being distributed to the areas where the population was now living.

I welcomed the Government's policies in "Making London Better", which stated that their overall objectives were to improve the quality of patient care for Londoners, to improve the services provided by the family doctor and other community-based health services, to ensure that hospital services responded to the changing demands of patients, to ensure that changes in medical practice—such as the growth of day surgery—were accommodated, to ensure that the high costs of overheads in London hospitals are progressively addressed and, importantly, to preserve and enhance London's reputation as a centre of excellence in treatment, teaching and research.

Of course, change of any sort is always difficult to accept in some quarters and sometimes it is even more difficult to implement. Many groups will lobby for their local hospital to remain as it is and support their local medical team in this endeavour. But I believe that the greatest problem caused by the reforms was the pall of uncertainty for the future which hung over many of our great London hospitals. However, when final decisions were taken by the Secretary of State for Health, I found that a return of confidence was quickly evident and an enthusiastic approach to "getting on with the job" was stimulated.

In 1993, the Health Select Committee visited the Lambeth community care centre and the Chelsea and Westminster hospital in May, and the Queen Elizabeth hospital for children and St. Bartholomew's hospital in July. In 1994, we visited the Charing Cross hospital in January; the Royal Marsden hospital, Chelsea site, in February; and the Hammersmith hospital and the Royal postgraduate medical school in April. We are planning to visit St. Thomas's hospital in May, and Guy's and King's College hospitals in June.

Wherever we have gone, we have been given a very warm welcome. I must place on the record the fact that I have not witnessed the atmosphere of total doom and gloom within these establishments which is being promoted by the press and Oppostion political parties. We have also called before us as witnesses members of the Tomlinson inquiry team, including Sir Bernard in December 1992; the London implementation group and its chairman, Sir Tim Chessels, in July 1993; and the Secretary of State and her ministerial team in March 1993 and March 1994.

Over the past week or so, there has been a great deal of controversy relating to the numbers of hospital beds available in inner London and the criteria that are being used to provide the exact figures. There is no doubt in my mind that, from what I have seen on my visits to London hospitals, the "number of beds" criterion should no longer be used to measure quality of care and effectiveness of health services. It is the number of patients who are treated and the quality and outcome of that treatment which are important. Beds are a very poor indicator of what can be and is being done in the NHS.

I will explain my reasons for saying that. On 13 April, members of the Select Committee visited Hammersmith hospital and were very impressed by the work that is being undertaken there. During our visit, Committee members were provided with the opportunity of learning about a procedure called interventional radiology, which is the branch of radiology dealing with non-invasive curative procedures under imaging control—for example, blocking or unblocking arteries, and removing gall stones or renal stones percutaneously and so on. These procedures are usually done under local anaesthetic and do not involve surgical incisions.

We saw for ourselves a procedure called embolisation, which is the branch of interventional radiology concerned with the occlusion of blood vessels in the treatment of bleeding, tumours or arteriovenous malformations. I will outline the case that we saw.

The man was in his early 40s. He had had pulmonary arteriovenous malformation since birth—that is, a hole between the opolmonary artery and vein. In his case, it was solitary, but in most patients they are multiple, often affecting both lungs. He was blue because 20 per cent. of his blood was shunting through the hole instead of being oxygenated. Many patients have strokes, as would probably have been the case with this patient, as a result of the condition because little clots of blood—we all have them—which should be filtered from the circulation by the lungs go through the hole and end up in the brain. That happens to 60 per cent. of patients with this condition.

The operation that took place was this: a tube, or catheter, was passed from the femoral vein in the groin, through the heart and into the hole in the lung vessels. This was done under local anaesthetic and was painless. The patient watched the procedure on television. The hole was plugged with a metal device called an embolisation coil, which was developed at the Hammersmith hospital. He did not feel anything and his blood oxygen saturation improved immediately—that is to say, he went from blue to pink.

Following the operation, the patient stayed in hospital overnight and went home the next day. He would be able to return to work in seven to 10 days, depending on his job. He has been cured and left with two healthy lungs.

Now I will tell the House what would have happened some years ago to that man with that condition. Half his lung would have had to be removed. Most patients with more than one lesion in the same lung require a pneumonectomy. If the lesions affect both lungs, which is usually the case, there is no treatment. A heart-lung transplant would be the only option.

The hospital can now treat these multiple cases—some patients have 60 to 100 plugs in their lungs. We should remember that chest surgery requires general anaesthesia and an operating theatre full of sterile instruments, people, blood to be cross-matched and so on. Chest surgery makes a large scar and requires stitches. It also involves a healing period and post-operative pain. It would thus have meant 10 days in hospital, with 10 or 12 weeks convalescence before returning to work. There would also be an increased risk of operative morbidity—that is to say, complications and a higher mortality rate than occurs with the embolisation method. Moreover, the patient would lose a normal lung, which means trouble in the future if the remaining lung goes wrong.

Interventional radiology can therefore reduce in-patient stay times and enable more patients to be put through the same beds. It can also abolish the need for the beds, as many procedures can be done on out-patients. The patient that I have described was in a hospital bed for one night instead of 10 days.

Let us not forget either that there are many other procedures which allow day surgery, because modern technology has created a completely different approach to illness and to many conditions—not to mention allowing some people to stay at home with their illnesses being properly controlled by drugs, instead of their being forced to resort to hospitalisation.

I repeat that bed numbers are not a reliable currency in health care. The concept is flawed.

The development of the procedure that I outlined earlier, however, requires centres of excellence to which patients can be referred for procedures to be devised and perfected by doctors. Whatever system the Government put in place, there must be provision to protect the resources of the institutions that generate the medical developments which will ultimately benefit the nation, in terms of quality of health care and of economics.

The good news from Hammersmith hospital is that the removal of the recent threat hanging over it has had important side-effects. Stability and confidence have been restored, and industrial and commercial financial support has flowed into the hospital for research. I am sure that the Government understand the enormous worry and disruption caused by the changes that are necessary in London's health care, and the importance of decisions being made as quickly as possible.

I hope that the Opposition parties, and others, will realise that times have changed dramatically and that the focus on bed numbers in inner London hospitals has become meaningless. There are fewer people living in London, following a continual population decline for 90 years. New procedures remove the necessity of long-term stays in hospital. New drugs keep patients at home instead of in hospital. Day surgery is now highly effective and efficient and the excellent facilities in hospitals in the provinces mean that patients need no longer come to London for sophisticated treatments. Primary health care and community services need to be the targets for improvement in London, and that is the area in which the Government should be promoting modern, high-quality health care—with support from all parties in the House.

6.22 pm

Mr. John Austin-Walker (Woolwich)

First, may I pick up a point made by the hon. Member for Southwark and Bermondsey (Mr. Hughes). I join him in welcoming the decision to include the time spent waiting for a first appointment with a consultant in the waiting time before a treatment. Certainly, for patients who are suffering while waiting for hospital treatment, it constitutes part of the waiting period and I welcome the fact that the Government have decided to count it as such.

Last year, I obtained information about waiting times in my district, specialty by specialty, from the family health services authority. When I put a question to the Secretary of State about the general position in London, however, the response was that the Department of Health does not keep such information centrally. That is one reason why this evening I want to discuss the absence of any strategic plan —or the ability to draw up one—for London because of the absence of a strategic health authority.

Clearly, if there is no strategic health authority for London the Department of Health must be responsible for collecting the information and keeping the statistics, but time after time when Ministers are questioned about London, the answer that they give is that the information is not held centrally.

The Secretary of State today talked of the blinkered ignorance of the Opposition. I wonder who she was talking about. It seems to me that anyone who criticises Government health policy these days is accused of blinkered ignorance. Would the Secretary of State, for instance, use the term to describe Professor Sir Colin Dollery? The right hon. Lady referred to the importance of research and of centres of excellence. Sir Colin, giving evidence to an inquiry set up by a London group of Labour Members, said that the Secretary of State's NHS reforms posed a major threat to research in London. He told our inquiry that the reviews carried out by the London implementation group had created low morale and had increased the problems of recruitment and retention of research staff in London".

Mrs. Roe

indicated dissent.

Mr. Austin-Walker

That is what professor Sir Colin Dollery told our inquiry last month.

The hon. Member for Broxbourne (Mrs. Roe) mentioned the excellence of the work at the Hammersmith. There is no doubt that such pioneering research and new techniques will lead, in a number of areas, to patients being treated more quickly, with less reliance on medication and with less trauma. It should, however, be recognised that modern techniques and research also mean that many more people can be treated in hospital for ailments for which there used to be no treatment. They used to suffer in silence and in pain at home. There is thus a double edge to these modern developments and they do not necessarily only mean that our reliance on hospital beds can be reduced.

The King's Fund has been quoted in defence of Government policies. My hon. Friend the Member for Newham, South (Mr. Spearing) quoted part of the King's Fund report, published this week, to the effect that adjusting the balance between hospital and community-based care will take time. New services must be put in place before old ones are declared redundant. The Secretary of State was keen to refer to the previous report of the King's Fund, but I draw her attention to the most recently published one. It states that to achieve sensible change without reducing health care for Londoners will require substantial new investment of resources in the capital. The report points out that, hitherto, that has been resisted because of the argument that London was overfunded. The Secretary of State and other Ministers have in the past quoted the King's Fund to support their argument that London was over-provided for, yet now the fund says that

the capital's health care needs have been underestimated. There are now good reasons for believing that London merits a larger—not a smaller—share of the NHS cake. Calculations by the King's Fund Research Institute suggest that purchasing power for hospital and community health services in London should be increased by approximately £200 million. I hope, therefore, that since the Secretary of State has placed so much reliance on the excellence of the King's Fund in the past, she will also take note of what it has said most recently.

Mr. Congdon

I have read the report carefully, even though it was delivered to hon. Members only last night. Does the hon. Gentleman concede that the figure of £200 million is merely an assertion? There are no calculations in the report to show how it was arrived at—

Ms Dawn Primarolo (Bristol, South)

Yes there are.

Mr. Congdon

Not in the report that we have received.

Mr. Austin-Walker

I hope that other colleagues will pick up the points raised in the King's Fund report, but I would point out that all the assertions that the Government have made in the past, basing their evidence on Tomlinson, were that London has been over-bedded and, therefore, overfunded. All the research in the King's Fund Institute report published this week shows that the argument that London is over-bedded is fallacious.

There have been suggestions that London is receiving too large a share of the cake. My hon. Friend the Member for Holborn and St. Pancras(Mr. Dobson) said earlier that London was receiving something like 15 per cent. of the share of the NHS cake and that London accounted for something like 15 per cent. of the total population. It does not seem as though the allocation to London is out of sync with the rest of the country.

My hon. Friend pointed out that, in terms of the police services, the Government recognise that London has increased needs, and, therefore, increased costs. There is a disparity in the Government's attitude towards the police and the fact that 29 per cent. of national expenditure on the police force goes to London to serve 15 per cent. of the population. Many of the factors that influence that in terms of cost and needs also influence the cost of the health service and the health needs of Londoners.

I shall refer to my own locality. The Secretary of State referred in passing to the Brook hospital. Unfortunately, my hon. Friend the Member for Greenwich (Mr. Raynsford) was unable to intervene. Greenwich health district comprises the constituencies of Woolwich, Greenwich and Eltham. There has been a 25 per cent. Loss of acute beds in the Greenwich health district in the past 10 years. Since 1982, the number of beds has decreased from 971 to 733. The number of beds in all specialties has reduced by 26 per cent. from 1,598 to 1,181. Across London, there has been an average loss of one eighth in the number of beds and in the health district serving my part of south-east London, the reduction has been a quarter.

Mr. Jessel

Did not the hon. Gentleman hear the clear and obviously sound arguments from my hon. Friend the Member for Broxbourne (Mrs. Roe) that the sheer number of beds should no longer be seen as a sensible yardstick of the amount of care that has been provided? He is carrying on with his speech as if my hon. Friend had not said that.

Mr. Austin-Walker

I do not disagree that modern techniques and improvements in care may mean that some patients will stay in hospital for shorter periods and that that will increase the ability for a throughput of patients.

I would point out, however, that 165,000 people on waiting lists in London are waiting to get into hospital. Reducing the number of beds does not seem to be a sensible way to get the list down. The problem is not that the beds are not being used; they are being used where the funds for nursing and support staff are available.

Particular problems face the health care and health district of Greenwich. The Greenwich healthcare trust is operating with reduced resources this year because it is gaining fewer contracts. That is partly because of the trend that some areas that used to purchase from it are now purchasing locally, but also because of the compliance with the requirements on junior doctor hours, that require the healthcare trust to reduce its operating costs.

The calculations that the local healthcare trust is making for the future are based on the possible availability in the near future of the Queen Elizabeth military hospital. I ask the Minister to address the serious problem which now faces Greenwich health authority and the Greenwich healthcare trust. There is still some uncertainty about when the Queen Elizabeth military hospital will be available—if at all—to the national health service and the terms on which it may come over. The health care needs of residents of Woolwich, Greenwich and Eltham will suffer severely if the Brook hospital closes without the Queen Elizabeth military hospital coming on stream to replace it. There is, therefore, an urgent need for decisions by the Department of Health and Ministry of Defence on the future of the Queen Elizabeth military hospital. A number of urgent planning decisions need to be taken.

The Secretary of State said that Opposition Members had made very little reference to the increased investment in primary care. I acknowledge that there is to be substantial increased investment in primary care in the Greenwich waterfront in Greenwich and Woolwich. I welcome that investment in primary care, but it is taking place in isolation from any consideration of its relationship to the provision of acute services in the area and the acute services review strategy.

One issue on which we would question the Government policy is that the Secretary of State's policy is based on the premise that London is ill-provided for in terms of primary care and that improvements in primary care will reduce the need for hospital beds and admissions. I am not aware of any evidence from any western country or from anywhere in the world that shows that improvements in primary care reduce the demand on hospital services.

All those who gave evidence to the London health inquiry, including the chair of the local medical committee, made a clear statement that improvements in primary care and access to it lead to increased, not fewer, demands on hospital services. It seems, therefore, that the Government are operating on a wrong premise.

In support of that I would adduce the recent comments of the Parliamentary Office of Science and Technology which suggest that improvements in screening and primary care will lead to extra nursing time, extra medical time, extra staff, extra in-patient days, extra out-patient visits and tertiary referrals to specialist centres. Many of the specialist centres in London are under threat by the Government review.

Will the Minister respond to the point made by Professor Sir Colin Dollery, that the Government's reorganisation of specialist units does not take any account of the possible capital costs of that relocation, which he has estimated at £1 billion?

It is not true, as the Secretary of State suggested, that Opposition Members have a total preoccupation with acute services and beds. I draw attention to the crisis in mental health in the capital city. The Mental Health Act Commission's report published in 1993 drew attention to crisis in inner city mental health services, including London. It stated: Implementation of section 117 Aftercare and the Care Programme Approach that is the section of the Mental Health Act 1983 under which patients detained have a right to aftercare on discharge from hospital— is barely evident in many inner city acute units. The high morbidity levels in the inner city populations, lack of alternatives to admission, problems of homelessness and poor community service, are contributing factors to the crisis in inner city mental health services". It is important that we address those issues.

The report of the inquiry into the care and treatment of Christopher Clunis, the Ritchie report, published in February 1994 specifies the high—more than 100 per cent. —bed occupancy rates in London's psychiatric units and the lack of supported accommodation. Those issues require the Government's urgent attention.

The House of Commons Health Committee report "Better Off in the Community" also referred to serious problems in mental health services in London. It expressed concern about the situation in some inner cities areas and contradictions in Government policy in the areas of health, housing and social security and identified the increased demands on mental health services which arise from social deprivation. That is a serious issue for most inner London boroughs and for some of the outer London boroughs as well, such as Newham, Haringey and others with a similar social make-up. The resource allocation formula needs to be reviewed to reflect that link.

The high level of homelessness affects the health service needs of the population of London. It does so in the sphere of mental health no less than elsewhere. The report of the Select Committee on Health pointed out the need for the allocation of resources specifically for housing. It identified the funding impasse that is preventing the development of permanent supported accommodation for homeless people with mental health problems who are living on the streets of London. The Government must address this matter urgently.

It has been suggested on a number of occasions that primary care and preventive measures may reduce the need for hospital beds. There is one way in which, in the long term, the need for beds could be substantially reduced. I refer to the fact that on Friday 13 May the Government could support the Bill being introduced by my hon. Friend the Member for Rother Valley (Mr. Barron) to ban tobacco advertising. The Government may argue that the bulk of tobacco advertising is aimed at persuading people to switch brands, but it is clearly a fact that between 100 and 150 people a day die as a result of cigarette smoking. One of the principal aims of tobacco advertising is to recruit teenagers to replace the smokers who have died. In London, the problem of tobacco-related illness is as great as anywhere else in the country.

I want to mention briefly the question of the environment, although I realise that some of my hon. Friends, if they catch your eye, Mr. Deputy Speaker, intend to talk about environmental problems in London. I shall refer specifically to air pollution. The part of London that includes my constituency and that of the hon. Member for Eltham (Mr. Bottomley) has one of the highest rates of asthma and respiratory illness in the country. We suffer from poor air quality. The Government's failure to tackle the problem of air pollution accounts for a major part of the demand on health care resources in the capital city. Their policies on health cannot be divorced from their policies on issues such as transport. In transport terms, but also in health care terms, it makes absolutely no sense for the Government to press ahead with their ludicrous programme of road building in south-east London, which will have such a detrimental effect on the health of the population.

My last point concerns the London ambulance service. Before becoming a Member of Parliament, I was responsible for introducing a report published by the Association of London Authorities on the crisis in the London ambulance service. That report pointed out many of the problems that the service faced at the time. The then Secretary of State for Health—now the Chancellor of the Duchy of Lancaster—dismissed it and accused us of merely being the mouthpiece of the trade unions. If the right hon. Gentleman had listened to the Association of London Authorities when he was Secretary of State for Health, we would not have the crisis that we are facing today.

I realise that the current Secretary of State has taken a personal interest since the computer went down and the London ambulance service crashed, but the most recent evidence is that since the right hon. Lady's intervention there has been no improvement in the service's response time. This is one of the most serious issues. It demonstrates that there is no strategic authority for London to plan ambulance services and that there is no system of accountability. Opposition Members not only insist that there should be a moratorium on the cuts and closures in health services in London, but argue for a system of accountability in respect of those services.

6.43 pm

Mr. Tim Yeo (Suffolk, South)

I am glad of the opportunity to contribute to the debate from the Back Benches. The subject is of deep interest not only to Londoners but to millions of people outside the capital, including many in my constituency. That is so not least because of the possibility—to put it no higher—that the perpetuation of a pattern of health provision in London that is not adapted to meet contemporary needs will pre-empt resources that could be used elsewhere in the national health service.

Before coming to the substance of that argument, I should like to take issue with the hon. Member for Southwark and Bermondsey (Mr. Hughes), who said that my right hon. Friend the Secretary of State was mistaken in spending time on an exploration of the reasons for the absence of the hon. Member for Sheffield, Brightside (Mr. Blunkett). It is of interest and concern to the House that, on a day on which the Opposition have an opportunity to choose the subject for debate, their principal spokesman on health should have decided to absent himself.

However, I can probably throw some light on the matter. My hon. Friends and I have come to realise that, after two years of mouthing slogans dreamt up by his trade union paymasters, the only achievements to the credit of the hon. Member for Brightside are, first, the removal of any lingering doubts about the wisdom and merits of the Government's national health service reforms and, secondly—and more surprisingly—the fact that he may have produced nostalgia and even affection among Conservative Members for the days when the Opposition's health spokesman was the hon. Member for Livingston (Mr. Cook).

However, all is not lost for the hon. Member for Brightside. The Opposition made an inspired choice in asking the hon. Member for Holborn and St. Pancras (Mr. Dobson) to lead the debate. I believe that the hon. Gentleman is the only Member of Parliament capable of making the hon. Member for Brightside appear to be intelligent, statesmanlike and original. Indeed, his speech was one of the most disgraceful and blatant attempts to exploit a very serious issue for very short-term political advantage. If the hon. Gentleman has done anything, it may be to have restored the reputation of his hon. Friend the Member for Brightside.

The two hon. Gentlemen have a common approach. Their speeches on health issues are designed to achieve two things—first, to please their trade union paymasters; secondly, to inspire as much fear as possible in the minds of patients by spreading misleading scare stories about the Government's health policy. That is matched by their absolute refusal to tackle any questions concerning the allocation of finite resources between competing priorities. Indeed, their determination to duck any remotely hard choice appears to be without limit. Perhaps it is matched only by the similar capacity that the Liberal party so often displays.

Despite the bluster in the opening speech of the hon. Member for Holborn and St. Pancras, in which he rather boastfully said that my hon. Friends to whom he had given way on a previous occasion had all lost their seats—

Mr. Dobson

All but one of them.

Mr. Yeo

Sorry—all but one of them. As soon as the hon. Gentleman was confronted with interventions from Conservative Members, who clearly knew a great deal more than he about the health service in London, he refused to give way for further interventions. I want to give him another opportunity to answer a question that he refused to answer earlier. Is it Labour party policy to increase the per capita spending on health in London? If so, does the party propose to fund the increase by reducing the allocation to other regions or by raising taxation? If it is the latter, I hope that the hon. Gentleman has cleared the matter with his hon. Friend the shadow Chancellor. I shall gladly give way to him. He failed to answer that question when it was put to him earlier. If he needs to phone his hon. Friend the Member for Brightside, there will probably be time to get an answer.

Mr. Dobson

First, I should like to make it quite clear that my hon. Friend the Member for Sheffield, Brightside (Mr. Blunkett) had a long-standing engagement to address a public health conference in Birmingham and to visit parts of the city, and he asked me to stand in for him. I was delighted to do so as the shadow Cabinet member with responsibility for London. I can reasonably claim at least some connection with the national health service in central London, as I and my family depend on it.

Complaints by Conservative Members about Labour's choice of a debate on health in London to take place in Opposition time are total cant and hypocrisy. The current Secretary of State for Health has not initiated a single parliamentary debate on health since she came to office. Until she does, it does not lie with her to criticise anybody. As I made clear in my speech—

Mr. Yeo

Answer the question.

Mr. Dobson

I remember the second part of the question: I am not stupid, as are some Conservative Members. In view of all the money that the Government's reforms are wasting in the health care system in London, a substantial part of any extra funds that are needed to provide services should come from getting rid of most of the management consultants, PR consultants and general hangers-on who have been ripping off the health service for donkey's years.

Mr. Yeo

The House will have noted the hon. Gentleman's complete failure to answer my question. He is not even as good as the Liberal party spokesman at ducking the issue. We now have confirmation that Labour party Front-Bench spokesmen plan to have health debates on days when their health service spokesman has longstanding engagements in Birmingham.

Mr. James Clappison (Hertsmere)

That is precisely the point that I was about to make. Does my hon. Friend agree that perhaps the Labour party could do with a few management consultants?

Mr. Yeo

My hon. Friend makes a most penetrating intervention.

The timing of the debate finally blows apart any pretence that the Labour party is genuinely concerned about the health needs of London. It is worried only about making political points and it has timed the debate just one week before the London local elections. That can only be interpreted as a desperate last-minute attempt to divert attention from the ghastly failures of Labour-controlled London local authorities.

Labour-controlled Lambeth borough council is currently collecting less than half the council tax that it should be collecting. Islington has almost £1 billion of debt, which is more than £5,500 per head of population—the worst figure in the country. The Labour-controlled boroughs of Hammersmith, Southwark and Lambeth have more than £64 million in uncollected rents. That is a massive waste of resources which is not only a terrible indictment of the management and administration of those boroughs, but an everyday tragedy because it denies services to the people of those boroughs.

Mr. Corbyn

The hon. Gentleman spoke about Islington. Will he confirm that the vast majority of its debt was approved by Ministers in the Department of the Environment, not by least the hon. Gentleman when he was a Minister in that Department, and that the money was borrowed to build houses and social service and other centres to provide a decent service for the people of that borough? Should the hon. Gentleman not at least concede that his Government are now preventing boroughs from developing the services that are necessary to assist with community care?

Mr. Deputy Speaker (Mr. Michael Morris)

Order. We must return to the health service debate.

Mr. Yeo

The matters that I have mentioned greatly affect the residents of those boroughs. I am glad for the on-the-record confirmation that the Department of the Environment does not block Labour-controlled London boroughs from borrowing the money that they need. At least there is a chance that next Thursday London voters will put all that right by returning Conservative local authorities. Meanwhile, we should celebrate the tremendous success and progress of the Government's health service reforms in London and the implementation of their new policies that are specific to London.

I warmly congratulate my right hon. Friend the Secretary of State for Health, who is the first holder of the office to address directly the complex problems of the pattern of health provision in the capital city. That is a clear example of the Government's willingness to address difficult issues and to introduce policies regardless of their short-term popularity. We want to do what is right for London in the long term. The Secretary of State has correctly identified the critical importance of improving primary health care and community services in London. Without those building blocks, nothing else that we try to do with London's hospitals or the rest of the health service will stand any chance of success. The Secretary of State and the Minister of State have shown great courage in addressing that matter.

For 100 years, reports identifying the problems in London's health service have been discussed, shelved and ignored. At last, we have a Government who are determined to put the situation right. Of course, the task is not easy and the concerns of people with direct experience of the great London hospitals must be respected. That experience may have been accumulated by those who were patients, students, nurses or doctors.

Through my family, I have direct experience of the excellence of the radiotherapy department at Charing Cross hospital. However, none of us should allow personal experience to colour our judgment of what is right for the future of health provision in London. It is easy and tempting to take on the attractive role of championing a great institution, and plenty of people are willing to speak up for individual hospitals. But, from direct experience, even more people have knowledge of the shortcomings and deficiencies of primary health care and community services. Because those concerns are not always as sharply focused and do not relate so directly to premises and institutions, they are not always articulated so loudly and clearly.

The Government's analysis is right. All serious analysts of the London scene—and, for a brief period, there was a hope that that might include the Labour party—recognise the need for fundamental and substantial change. Merely because a hospital has a famous history does not mean that it should be preserved for all time in aspic. My hon. Friend the Member for Broxbourne (Mrs. Roe), who is the Chairman of the Select Committee on Health, spoke about the advances in medical treatment which have greatly shortened hospital stays.

Nowadays, far fewer people wish to travel to London from the provinces. Patients do not come from constituencies such as mine in the same volume to great London teaching hospitals, because the high-quality care and treatment that was previously available only in London is now far more extensively available and people prefer to be treated much closer to home. As a result, the London hospitals depend far more than ever before on serving the needs of their local populations.

The introduction of the purchaser-provider split has been a huge spur to greater efficiency. It has allowed a rationalisation of resources which in itself can be immensely beneficial. Eleven years ago, when the Great Ormond street special health authority, as it then was, proposed the closure of the Tadworth Court children's hospital, I led a campaign that was backed by the leading voluntary organisations to save the hospital. The proposals that we put to the then Secretary of State for Health and Social Security were accepted and they were a kind of precursor of the NHS trust model.

We established the Tadworth Court trust as an independent charity, which I chaired for the first seven years of its existence. By refining the services offered by the hospital so that they were more responsive to the needs of what we would now call purchasers—in this case Great Ormond street itself and some of the neighbouring health authorities and, indeed, some local authority social services departments—we were able to increase the use of the facilities at Tadworth, improve the efficiency and, therefore, lower the costs of the services there, and to release a huge amount of surplus assets in the form of land. Those assets were sold for about £15 million, which was available to boost the Great Ormond street capital programme. That is a clear example of how rationalisation, which sometimes seems threatening to people because of its possible consequences, can produce benefits all the way round.

The real test of the Government's health service reforms and their policies for London will be in assessing whether they have achieved the improvements in primary health care that are so badly needed. The resources identified by the Secretary of State for Health that are going to many areas of the London health service, but especially to primary health care, should be used not just to improve the general quality of primary health care, but to raise the calibre and the level of staffing and to extend the present trend of improvements to GP premises. Those are important steps.

The hon. Member for Woolwich (Mr. Austin-Walker), who has briefly left the Chamber, tried to suggest that improvements in primary health care do not affect the demands on hospitals. Nothing could be further from the truth. It is clear that there are excessive demands on the accident and emergency services in a number of London hospitals which are directly attributable to the inadequacy of the primary health care system in those areas.

Alongside the improvements in primary health care, we need to see improvements in the community services, and those will depend on good co-operation between the health authorities and the local authority social service departments, regardless of their political complexion. If we see those improvements, there will also be the prospect of easing some of the pressure on the expensive central London acute hospital beds, because people will be able to be looked after more quickly following treatment in the community.

The Government's analysis of the situation in London is correct. The actions that they have set in motion are also correct. The tragedy is that the Labour party has become so obsessed by politics and votes and by the need to obey the demands of its trade union paymasters, so divorced from the reality of the health needs and the welfare of the patients in London, that it is now unable even to enter into a rational debate on this vital subject.

The way in which the issue is being exploited on the basis of a dishonest and distorted view of the facts presented by the Labour party is deplorable. The hon. Members for Holborn and St. Pancras and for Brightside appear ready to stoop to levels from which even the hon. Member for Livingston might have refrained two years ago. They appear to be conducting some sort of Dutch auction to see how low they will take the standards of debate.

But the voters and the patients will draw their own conclusions. I believe that next week the Labour party will be rejected on a massive scale across London. People will want to back Tory measures to strengthen London's health service.

7.1 pm

Mr. Jeremy Corbyn (Islington, North)

That was a most interesting contribution from the hon. Member for Suffolk, South (Mr. Yeo). I have often thought that one of the problems of Parliament is the amount of politics that goes on within it. It is quite shocking and deplorable.

Mrs. Bridget Prentice

Something must be done about it.

Mr. Corbyn

My hon. Friend is quite correct. I am not sure what, but something should be done about it.

I am rather looking forward to a speech from one of the London Conservative Members. I believe that there still are some and presumably at some point they will try to speak, but thus far we have heard nothing from them. We have heard Conservative Members from the fringes who have inherited some London people in their constituencies, but nothing yet from a London Conservative Member; we look forward to that.

I thank my Front-Bench colleagues for choosing today's debate on the London health service. It is an extremely important subject and such an opportunity is welcome. I was particularly amazed by the Secretary of State's contribution. My hon. Friend the Member for Newham, South (Mr. Spearing) and I have worked out the pattern of her speech. It was rather like cracking a cipher. It was written by a committee of six people. They took it in turns to write a paragraph and then started again at the beginning. That is why the speech hopped from subject to subject so many times and kept coming back to where it started.

The debate underlines an extremely serious situation in the health service in London. The Government, who have been in office since 1979, have presided over a large number of hospital closures and wholesale changes in the structure and philosophy of the NHS. From a service that was free at the point of use in 1979, the god of the internal market now controls everything; there is massive privatisation within the NHS and there are serious problems with morale and the way in which people are employed.

Members of my union, Unison, used to feel that they had secure, if not well-paid, jobs within the NHS. They felt that they were there to contribute to the NHS and they did that with extreme dedication. Many of them now suffer the indignity of their jobs being put out to auction every five years in order to find the lowest bidder as more and more services are contracted out. The responsibility of those people who have given such wonderful service to the NHS has never really been recognised by the Department of Health.

If the Government had not been so arrogant for the first 12 years in office and had stopped to listen to what ambulance drivers, workers, officers and paramedics were telling them about the state of NHS ambulances in London, purchasing, the computer and safety, something would have been done earlier. It took the inspirational work of members of the National Union of Public Employees and the Confederation of Health Service Employees, now in Unison, and my hon. Friend the Member for Newham, South during his many efforts in the House, to expose what was going on in the London ambulance service and eventually, belatedly, reluctantly, the Secretary of State did something about it. We are still not following Orcon standards in London. We are nowhere near reaching those standards, and a great deal still needs to be done in the London ambulance service. I give that as just one example of the problems created by the Government's attitude towards the health service in London.

The problem is compounded by the obsessive secrecy surrounding the internal market. I recall a meeting that I had with the former manager of the London ambulance service who, fortunately, saved us all by resigning. I asked him whether he could give me the figures on the costs of vehicles and running the London ambulance service. The answer was that it was a commercial secret. He said that it was commercially confidential information. That was from an NHS manager in an NHS-funded operation, because the service was being prepared for privatisation through contracting out. That is what happens when a service as important as the health service is allowed to be dominated by the internal market.

Many hon. Members have referred to population loss, particularly in inner London, the closure of hospitals and waiting lists. As hon. Members were speaking, I was thinking of the number of hospitals that I have known to be closed during my time as a union official in NUPE since 1975 and as a Member of Parliament since 1983. In my locality, for example, the Royal Northern hospital, a wonderful institution on the Holloway road, the borough's war memorial, has been closed. The first letter that I received from a Minister withdrew the pledge given by his predecessor in 1982 that the closure of the casualty unit at the Royal Northern did not presage the closure of the whole hospital. The first letter that I received from a Minister said that he was sorry, but that was a mistake; it did presage the closure of the entire hospital. That hospital is now closed and has not been replaced. It has been replaced by one new wing in the Whittington hospital just up the road, with fewer beds than before and a longer waiting list.

It says something for the competence of the Department of Health that the Secretary of State was dispatched to open the Great Northern wing of the Whittington hospital last August. What she did not realise was that she was opening a building that had already been partly closed. She was a bit late. A number of wards had already been taken out of operation as a result of lack of funding.

We have the nonsense in London of 165,000 people waiting for hospital appointments and 22,000 beds recently taken out of operation with an increasing number of beds simply not being used because the money is not there to pay the staff. That is an insult to the people of this capital city.

The Government's solution to the crisis was to set up the Tomlinson inquiry. That could have been a good opportunity for a genuine public inquiry with participation by the people of London—doctors, nurses, consultants, trade unions, community health councils, various health campaigns, bodies representing the elderly, those with disabilities and the homeless; all could have made a contribution to a serious inquiry into the future structure, funding and quality of care of London's health service. But not a bit of it.

Mr. Spearing

A one-man band.

Mr. Corbyn

Precisely. We had a one-man band and a secretive operation that came out with a report that proposed a further removal of 4,500 beds and which, as we speak, casts a shadow over the future of a further 16 hospitals. There has been no openness about it. The whole thing has been dominated by the desire to cut costs and to enforce the internal market and the purchaser-provider split, without giving a fig for the people of London and their concerns.

In my brief contribution, I want to refer to the work of a group of London Labour Members which should have been done by the Secretary of State. We undertook an inquiry. We took evidence over 10 and a half hours from a number of people. Obviously, we could have taken a lot more evidence and the inquiry could have gone on much longer, but we felt that it was reasonable to take that amount of evidence, backed up by a great deal of written evidence. Many people gave their time, their information and their energy to tell us what was going on in the NHS in London. I shall quote briefly from Professor Peter Barnes of the National Heart and Lung Institute, who said: This Government has destroyed the good will of health workers". The inquiry report says: There is clearly a failure in the NHS to consult those who work and use the system in London … Many of the submissions received contained pleas for medical ethics to take precedence over the market ethos. How often has one talked to nurses, doctors and others who have asked why they have to spend all their time filling in forms about the purchase and the cost of particular medicines? What is it like for doctors to say that they no can longer prescribe Calpol because it has been taken off the list? Those are problems at one level, but we may move to a more serious level due to the obsession with cutting costs and with enforcing an internal market in the health service.

Our inquiry also demonstrated the many problems that exist in London and the relationship between poverty and ill health. Many, such as Rowntree and Charles Booth, have done work on that subject and have shown that the greatest cause of ill health in this capital city is poverty —poverty through an inadequate public health system, inadequate drainage and inadequate medical services and other such facilities. The slum clearance programmes and the drainage programmes were part of the growth in health provision.

What do we have now in London? There are 750,000 people who rely on wages that are well below the poverty level, and the costs of living in London are considerably higher than in the rest of country. One in four of all London children rely on free school meals, often as their main source of nourishment. The only reason why they are eligible for free school meals is that their parents' incomes are on the level of income support or below. That is a serious problem. In many schools in my constituency—I am sure that my hon. Friends who represent other inner London constituencies find the same—80 or 90 per cent. of the children who have school meals get them free because of the poverty of their parents.

Mrs. Bridget Prentice

Will my hon. Friend also comment on the relationship between poverty and health and the figures that I have received from the Department of Health about the number of notified cases of tuberculosis in England and in London? There were 855 cases in 1992 in England as a whole, 258 of which were in London—almost a third in London alone.

Mr. Corbyn

My hon. Friend underlines an important point. If my memory serves me correctly, she has just said that almost a quarter of the cases of tuberculosis occur in London; and London does not have a quarter of the nation's population. Many of the poverty-related illnesses, which were the bane of Londoners in the 19th century and in the early part of the 20th century, are returning. The poverty-related chronic illnesses, which were written about so well by many of our forerunners in the House, are on their way back.

Mr. Ian McCartney (Makerfield)

May I refer my hon. Friend to the recent report of Crisis at Christmas, which shows epidemic levels of tuberculosis among London's homeless?

Mr. Corbyn

My hon. Friend is correct. It is hardly surprising that people who are homeless end up with tuberculosis. If homeless people are forced to sleep in bus shelters, tube stations or on the streets of London outside expensive hotels and empty, privately owned flats, it is hardly surprising that they contract chronic illnesses. Indeed, our inquiry received evidence from one of the homeless groups that the life expectancy of a man who is homeless on the streets of London is 46. That is an appalling figure and an indictment of our society. We need a health service and an attitude that deal with those problems.

The standardised mortality rates in London, on the analysis of the King's Fund, show that 30 per cent. more residents of inner London areas in the 15 to 64 age group die annually than would be predicted on the basis of national figures. That confirms the point made by hon. Friend the Member for Lewisham, East (Mrs. Prentice) about tuberculosis. We have a serious problem.

On top of that, what do we get but a continual decrease in the number of available hospital beds and the great difficulty that many of those people who are suffering extreme poverty face in getting a GP in the first place? We gathered evidence from those who deal with such matters. They said that it was very hard for many homeless people to become registered with a GP. Obviously, they have to go to a casualty unit instead to try to obtain treatment.

I recognise that, as the Secretary of State mentioned, the unit that has been opened in the Camden and Islington area is a step forward. However, it would be an even better step forward if GPs were put under some pressure, which ensured that they took on refugees, people whose first language is not English and people who are homeless, because there is evidence that some GPs are reluctant to take on people who fall into those categories.

I am not tarring all GPs with the same brush. Many GPs do an absolutely first-rate, excellent job and are generally concerned about the health of the entire population. However, something must be done about the problems that were illustrated by our inquiry. The Department of Health reported that between 8 and 14 per cent. of patients who were seen by London accident and emergency units were not registered with a GP. Clearly, there is a larger number of people than that who are not registered with a GP.

The Government are talking about transferring resources from hospitals to primary care. We have seen plenty of closures of hospitals and hospitals services, but we have not seen a commensurate increase or improvement in expenditure or in the service provided in a large number of facilities in the primary care sector.

I hope that the Government will be prepared to recognise that there are links between poverty and ill health. There are links between the environment and ill health. Why is it that in many schools in London a quarter of all children are suffering from asthma of some sort, as my hon. Friend the Member for Woolwich (Mr. Austin-Walker) pointed out? If one goes into a school secretary's office, one sees a whole shelf full of nebulisers for children who suffer from chronic conditions of asthma, which is related, in part, to the growth of road traffic and of air pollution as a result. What utter madness to spend so much money on motorways, when we could be improving public transport and reducing pollution. We must consider those problems.

What also came out in our inquiry was the concern of many people for the future of not only special hospitals, but of research institutions in London. Sir Colin Dollery from London university gave interesting evidence in which he expressed deep concern about the future quality of medical research that can be undertaken in London because of the way in which the internal market runs and because of the lack of funding of those resources. I suspect that he was one of many who share that view.

We must also consider the problems of individual hospital closures and the campaigns that surround them. The list of some 16 hospitals in inner and outer London which are all under some threat includes Guy's, Dulwich, Hither Green, St. Bartholomew's and the Queen Elizabeth hospital in Hackney.

I was at a public meeting on Tuesday evening which concerned the future of Bart's. It was a local meeting, near to the hospital in the borough that I represent with my hon. Friend the Member for Islington, South and Finsbury (Mr. Smith). It was packed. The people there were devastated that the courts had ruled against the application made jointly by the London boroughs of Islington and Hackney to keep the hospital open. However, they were absolutely determined to fight for their hospital. That hospital has been there for 900 years. If one talks to anyone outside London—

Mr. Spearing

Or in the world.

Mr. Corbyn

Indeed, if one talked to anyone, anywhere in the world about closing an institution of the excellence and with the record of Bart's, they would think we were completely mad. I suspect that we shall be left with a closed hospital and an empty office block on its site.

As for the idea that people should go elsewhere for health care, I refer to the words of the Secretary of State. She said that it is important for the services to go where the people are. Where will the people who live around Bart's, who use Bart's and who come from elsewhere to use Bart's go? How will they get there? That will create serious problems.

Serious problems are also caused by the closure of casualty units and the difficulties for ambulances in travelling through London during the rush hour at crisis times. It is not good enough to say that the air ambulance can sort out that problem. There is one air ambulance and that cannot sort out the problem. It will be solved only by maintaining the existing casualty units, which have provided such a good service in London for so long.

There are many other issues relating to the health service and I hope that they will be mentioned by other hon. Members during the debate. London has the principles of a very good health service. There is enormous public support for the principle of a national health service free at the point of use. Even the years of Tory Government have not managed to destroy the principle of a free national health service, despite the Government's considerable efforts to try to do so.

What we do not have in London is any sense of democracy in the planning or running of our health services; we have a secretive inquiry by one person who proposes wholesale cuts and closures; placepeople running the regional and the district health authorities; and the mania for the internal market dominating everything that goes on in every hospital and health service institution throughout London.

What we need is some democracy in the running of the health service. We need a London health authority that can plan for the needs of the capital city and preserve the centres of excellence that have given such good service, not just to the rest of this country but to the rest of the world. Instead, we are getting a domination of the service —domination by the internal market, domination by the worst aspects of accountancy, and a consequent loss of so many people's morale and faith in the health service.

The debate is very important and timely. Those who are trying to destroy London's health service—and I believe that some are—will rue the day that they did such things. It is important that we understand that the people of London are suffering from unemployment, poverty, ill health and a lack of certainty of the availability of an ambulance or hospital bed when they so desperately need it. Nothing that has been said by Secretary of State or the Tomlinson inquiry does anything to take away those concerns and fears.

We are suggesting today a London health authority. London is not over-provided for or over-bedded; if anything, there is under-provision. We want a recognition that if we are to have a healthy capital city, we must be prepared to spend the necessary money to pay for it. Closing hospitals is hardly the way to start doing that.

7.21 pm

Mr. Andrew Rowe (Mid-Kent)

I have sympathy with one of the points made by the hon. Member for Islington, North (Mr. Corbyn). He is quite right to draw attention to the inter-relationship between the health of the nation, or the health of an individual, and the surrounding circumstances of his or her life. Indeed, much of what was behind the thinking of the NHS reforms was to make the links between the other services that impinge on somebody's life and health very much easier to make and build constructively than they were in the days when the NHS was dominated by the medical establishment and saw everything in medical terms. I shall return to that in a moment.

The service is changing very fast—although in most of the speeches of Labour Members, it would be hard to recognise that. I hope that, as the service develops, we shall see changes in role differentiation. For example, one reason for the logjams in some accident and emergency departments is that the medical profession is frequently very reluctant to delegate, as they are empowered to do, relatively simple surgical procedures to nurses with great experience and every capacity to perform them. I very much hope that the job specifications—rigid in many cases —that exist in the NHS will be undermined, as there is growing confidence in the professional capacity of other non-medically qualified staff.

There are important debates to be had about the extent to which a medical model is necessarily the best for the delivery of quite a lot of the services that impinge on people's health. I very much welcome the way in which the reforms have lowered the walls between the disciplines, but there is still a long way to go. There is still too automatic an assumption of superiority among doctors, conferred by six or more years of initial training. On the other hand, in too many other specialisms in the NHS, far too little account is taken of the necessity for good research. I believe that both parts of the NHS have a great deal to learn from each other.

The NHS remains far too hierarchical in the way in which decisions are taken. Again, I welcome the growth in co-operation between social services, education and the NHS, and the growing respect that is coming between the different professionals in their different ways. I urge my hon. Friend the Minister to strike a balance between the managers and the specialists, and ensure that decisions should not always go in favour of the managers. Genuine anxiety is felt by people who have given their lives to the NHS, and they sometimes feel that very enthusiastic macho managers do not pay them the respect that their experience deserves. That is a growing pain of the changes, but an important one to bear.

The hon. Member for Sheffield, Brightside (Mr. Blunkett) came down to my part of the world recently, and among other adjurations that he directed to a medical and quasi-medical audience was that we should be prepared for massive technological changes coming over the NHS. So we should. I believe that it is now only a matter of time before the professional expertise of a specialist can be beamed down to many areas of the country, so the need to be physically in contact with the specialist might well diminish.

I welcome that, because it will mean a further diminution in the necessity for the leading consultants' units to be within easy reach of Harley street, which, of course, is why most of the great teaching hospitals grew up where they did. It is an anachronism to have such a concentration of elderly—or antique, if one likes—specialisms in such a small area. It is conceivable, and I am sure that it is true, that there are probably too many managers in the NHS at the moment, but I do not see that as anything other than a necessary temporary phase, for a variety of reasons.

Before we take the numbers as an absolute, let us remember that many of the new managers are specialists —medical, nursing, speech therapy or whatever—and have taken on a management function and been given a management title. The idea that they have become a different breed is nonsense. In the early stages of turning around an NHS that did not have the faintest idea how much any of its procedures or operations cost, we are bound to require a good crop of managers while we put in place the systems that are needed to work out that cost.

One source of great aggravation and hostility to the NHS reforms is that, for the first time, consultants are finding that their time is being managed. Far too often in the past, consultants were able to slip out of the hospital for long periods, leaving the responsibility with their junior staff. Of course, many have been enormously conscientious and work all the hours that God sends, but a whole crop among them have not.

One of the best features of the NHS reforms has been the transfer of the consultant contract from the regional health authority to the local unit that worries about where its most expensive members of staff are. The other element of management that is new is the serious attempt to manage the assets of the hospital as a whole. In the past, consultants had beds and, if they had a good working relationship with one of their fellow consultants, they might allow them to make use of it if they were not using it. There have been many examples in the past when beds were managed not as part of a hospital's total assets but simply as part of a consultant's assets. That is a substantial potential change for the better.

The fact remains that we can see self-interest or vested interest when it appears in the debate. The Labour party has moved the motion out of naked self-interest. Every citizen wants to be healthy, preferably at no cost to themselves in terms of either cash or self-discipline. As none of us looks forward to getting old, and as each of us has a friend or relative who is old, ill or in pain, it is easy to strike a sentimental chord. We know that there is never as much resource as we could use in the national health service, so it is easy to create fear, anger or demand—and the Labour party cynically chooses to do so in the run-up to the local elections. Votes are one self-interest.

Another self-interest is the grip that the national health service unions have on the service, which is being shaken by the reforms, and that of the British Medical Association. Unison—that is a curious misnomer—used to enjoy the privilege of striking when it suited. The professional associations generally lead the clamour for the status quo.

The status quo consists of a bland acceptance of the myth that all the ancient teaching centres are equally effective, whereas it is clear that the quality of the research done in some of those centres is very uneven, and some of it is downright poor. A good deal of the teaching in those centres no longer deserves the reputation that it enjoys.

The status quo consists of expensive services being provided where people no longer live. Sometimes it consists of a dependence on the old boy network, which certainly needs to be re-examined. It also consists of a concentration of services in inner London, to the detriment of services elsewhere, in areas such as mine, to which the people who used to live in London have now moved out, as the hon. Member for Islington, North said.

In Medway, we welcome the Government's courage to make changes. They have announced that £45 million will be spent on the Medway hospital. My three Medway colleagues and I are glad to welcome that. That £45 million will lead to the closure of beds and units, and I welcome that as well.

The paediatricians in All Saints, Chatham, who have coped magnificently in the passages of the old workhouse, will rejoice that, in a few years' time, they will be working in a new building in a modern hospital complex. I am prepared to bet that there will be a public outcry against the closure of All Saints, Chatham—that old workhouse—because it is in the nature of people who have been in hospital and come out well to feel a warmth towards that institution, which leads them to protest when it is closed, despite the fact that closure frequently leads to better provision somewhere else.

One of the other consequences of the reforms has been the state-of-the-art oncology unit in Maidstone. We are also grateful for that. We shall soon see local centres of excellence growing up all over the country, rather than concentrated in a few large cities. We know that it can be done. Papworth hospital, Stoke Mandeville hospital, the hospital of East Grinstead, and Leeds general hospital have all shown how centres of excellence can be created well outside London. Modern technology will make that easier.

I also welcome the good news unit which the hon. Member for Holborn and St. Pancras (Mr. Dobson) was so pleased to rubbish. Nothing destroys morale more fundamentally than to have one's service portrayed as constantly in crisis, as Labour spend its life doing. Staff at all levels welcome good news. They welcome the chance to borrow successful ideas from each other and to show off their own. I hope that the flow of good news will swell until it drowns out the Jeremiahs in the Labour party.

Fortunately, the go-ahead, thoughtful professionals recognise the need for change, and the professional associations are finding themselves either increasingly co-operative or increasingly outflanked. Those that are being outflanked turn to the Labour party, which is as far away from being go-ahead and thoughtful as it is possible to be.

Of course, they do not turn in vain. Look at what we have been given—the argument that if an organisation is old enough, it must be preserved, and a total refusal even to consider the consequence of a fall in population from 10 million to 7 million. Labour have complete amnesia about the 25 reviews of London's health service which have taken place this century, and we now have a demand for yet another review. The Labour party resembles an old people's home, an elephant's graveyard and a place where radical ideas go to die.

Finally, the national health service reforms in London are behind the rest of the country. What we need to see in London is the sort of development that we have seen in my part of the world, where, for example, with skilful management and good co-operation among our primary healthcare trust, our acute care trust, the general practitioners and social services, we now have a team working together to ensure that, when patients are discharged from hospital, they are properly looked after in the community, and that no patient leaves hospital without having full arrangements made for that discharge. That is absolutely right. I share Florence Nightingale's view: Never think you have done anything for the sick of London until you have nursed them in their own home.

7.36 pm

Mr. Jim Dowd (Lewisham, West)

The speech of the hon. Member for Mid-Kent (Mr. Rowe) was startling for its insensitivity and lack of appreciation of the problems facing London. If we are to believe Tory Members' claim that the population has moved away and the health care patterns have not, we would be witnessing a surfeit of services for the people of London—they would be spoilt for choice. There would be so much concentrated here to serve so few that people would be tripping over available beds in hospitals. The reverse is true, and that is why we asked for this debate today. Many of my hon. Friends wish to speak, so I shall chop my comments as much as I can, which I am sure will be appreciated by everyone.

I was a member of the area health authority for Lambeth, Lewisham and Southwark—I was first appointed in 1976. I subsequently served on the Lewisham and North Southwark district health authority, as it became known. I have therefore been closely involved in the development of health care in south-east London for a number of years. Like my hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson), I shall make a few personal and domestic comments.

My sister and brother were born in the early 1950s under the aegis of the home care delivery unit at Lewisham hospital. My younger brother was born at King's College hospital. A few years later, my father died at Guy's, my mother died at King's College hospital, my daughter was born in Beckenham hospital, her son was born in Farnborough hospital, I had a nephew born in Lewisham hospital last year, and, sadly, my father-in-law died in Hither Green last October.

Fortunately, on the only occasion that I have ever had to be admitted for in-patient surgery, I attended St. Thomas's hospital for a bone graft about 30 years ago. I say that simply to show that my involvement in health care services in south-east London is both deep in political terms and personal in the way in which they have supported me and my family over many decades.

When we discuss health, and I am able to catch your eye, Mr. Deputy Speaker, I never lose the opportunity to point out that the Tory attitude to the health service is grossly compromised by the fact that the Tory party was against its establishment in the first place. All those years ago, the Tories opposed it.

Mr. Duncan Smith

rose—

Mr. Dowd

I will give way in a moment, but I am more inclined to give way to hon. Members who have been here for a considerable time, rather than to those who merely flit in and out.

The Tories are embarrassed because they opposed the establishment of the NHS. It has never been made plain at what stage that view changed and when they suddenly became its supporters. They would like us to believe that they are its instinctive and natural supporters, but the truth is very much the reverse.

Their experience is sad because the health service is the one area of public life in which the freebooting, rabid ideology of the right-wing element that holds the modern Conservative party prisoner cannot give that ideology full rein. It is the one area which accords most strongly with the highest ideals and fundamental needs of the British people, and the one area which affords the Conservatives the greatest difficulty.

Mr. Duncan Smith

I have been in a Standing Committee since the debate opened, which is why I was not present for earlier speeches. The hon. Gentleman says that the Conservatives were against the establishment of the health service, which is not true. The reality is that the doctors also opposed its establishment, yet we do not hear any condemnation of them, so the hon. Gentleman is making a spurious point.

Mr. Dowd

As most doctors are card-carrying Tories, it is hardly surprising that they opposed it. [Interruption.] That is my experience and recollection of 40 years ago.

Mr. McCartney

They are in favour of it now.

Mr. Dowd

As my hon. Friend makes plain, their experience in the intervening 40 years has caused them to recons0ider their view with some rapidity and regret.

To listen to Conservative Members, one would think that there had never been any reviews of the health service in London, or any changes in hospital formation and deployment. When I first joined the area health authority about 18 years ago, there were more than 16 hospitals in Lambeth, Lewisham and Southwark. Today, there are only four, or one quarter of that figure. That is why we were so concerned about the proposal to reduce it to three.

Change is an ever-present factor in London. It is bogus and completely bizarre for Conservative Members to try to pretend that that has never been the case and that they were the first to propose a far-reaching and dynamic view of Londoners' health care needs.

Conservative Members have said that no change is not an option. They recite it like a mantra—I suppose that it keeps them happy. It is not an option in any walk of life. Change is permanent, especially in large organisations such as the health service, and it has to continue. Any competent manager in an organisation, whether public, private or any other kind, must consider its position in the changing circumstances of the world. Change is a perpetual element of the management of any service.

What we will not believe—but what we are being asked to—is that we must accept the Government's and the Secretary of State's recipe for what form that change should take. We resent that and we reject it.

My hon. Friend the Member for Woolwich (Mr. Austin-Walker) mentioned the absence of a strategic health authority for London, although we seem to be moving slowly towards one with all the reorganisations tinder successive Conservative Governments. We are now down to two regional health authorities covering London—one in the north and one in the south. The next stage will be the transition to a single health authority for London, which will benefit from it. That regional view of health care needs will make the preparation and consideration of plans for London far easier.

Mr. Spearing

I think that we all want a London hospital authority that is directly accountable to Londoners. After all, London has a higher population than Scotland. However, does my hon. Friend agree that the North Thames and South Thames regional health authorities extend well beyond the London area, to the south coast in one direction and well into the south midlands in the other? The Government are therefore not heading in the direction that we had both hoped.

Mr. Dowd

I thank my hon. Friend for that intervention. I was saying that there had been movement in that direction, and that the next stage would be to recognise that London has needs that cannot be dealt with in the same breath as Brighton's or Bedford's. However, I accept my hon. Friend's point.

The Tomlinson report was a substitute, because of the lack of an organisation able to give that strategic view. Tomlinson was forced on the Government because of the colossal damage that was being done to the acute sector of the health service in London by the so-called reforms and the emergence of the internal market. As my hon. Friend the Member for Islington, North (Mr. Corbyn) said, the Conservatives have wasted the opportunity that that report provided.

I was a member of the health authority when the flagship trust of Guy's and Lewisham was created. The Lewisham end of the operation was certainly told that it could survive only with a closer, umbilical link with Guy's, and that if it tried to go it alone, it would have no future.

There was a totally bogus consultation exercise. The health authority, of which I was a member at the time, undertook that the consultants would each be given a vote on whether the Lewisham and Guy's trust should be created in 1990. They were asked whether they wanted the flagship trust to be established.

Some of us managed to get a second question put on the ballot paper. We asked whether the Government's planned reforms of the health service would be in the best interests of patient care. The consultants—highly skilled and knowledgeable people, who one imagined knew what they were voting for—voted by a majority of two to one for the formation of the trust, which subsequently came to pass. About 200 or so took part in the ballot.

However, they voted by four to one against the premise that the Government's proposals to change care would be in the best interests of patients. I felt, to put it mildly, that it was an act of considerable hypocrisy, but they felt that they could do naught else.

The flagship set sail, but we now know what came to pass. The flagship has been scuttled; it was sailing under a flag of convenience and nothing more. When a greater imperative fell upon the Department of Health, it decided that Guy's needed to go in with St Thomas's. However, as I said on the last occasion that I spoke on the matter in this Chamber, the Guy's and St Thomas's merger was nothing more than a mask for the closure of one of the two. We now know which one.

It also decided that Lewisham was well placed to go it alone. The recommendation said that it was extremely well placed to survive as an individual, independent trust, which is the very reverse of what it had been told not three years before by exactly the same people. Either they were lying in 1990 or they are lying now, because both cannot be true—

Mr. Deputy Speaker

Order. Will hon. Members on both sides forget the word lying? As I have said before from the Chair, it leads us all into difficulties, and there are ways to rephrase it.

Mr. Dowd

Very well, Mr. Deputy Speaker. I accept your admonishment. Both statements could not have been true, as they were only three years apart.

I heard the Prime Minister mention Lewisham hospital in glowing terms today, as did the Secretary of State. Their optimism and their glowing remarks were not founded on one whit of knowledge about what is happening there.

I wrote to the hospital on behalf of a constituent who was waiting for an operation. Sadly, although the constituent was in pain, having waited a considerable time for treatment, the case was not out of the ordinary. The final paragraph of the letter that I received from the consultant ear, nose and throat surgeon says:

In the light of the Secretary of State's recent announcements regarding Health Service provision for London, I would suggest that you join the campaign for the maintenance of medical and surgical beds in our vicinity as the problem for delivering services to your patients will increase substantially. While this may only put a strain on the community for those patients with recurrent infections, it will undoubtedly lead to the premature death of others, permanent disability for some and great sadness for those who are their dependants. I have a copy of a report from the chief executive of Lewisham hospital, who was given an NHS leadership award—whatever that is—not long ago. Apparently only nine were given out, and she was one of only three women to receive one. I have come to the conclusion that nowadays the upper ranks of the NHS—the world of senior managers and accountants—resemble the Mad Hatter's tea party, in that everyone wins and all must have prizes, while those on the front line providing care are given redundancy notices. That is certainly happening in Lewisham.

As both the Prime Minister and the Secretary of State went out of their way to say how enthusiastic people in Lewisham were about what is happening, let me read a small part of that report: From Lewisham's perspective, despite the continued confirmation of our secure future as a 'fixed point' in South East London, (as emphasised by SELHA, Tomlinson and the Secretary of State) the reality feels somewhat different. Over the last four years, we have made savings of between 4 per cent. and 7 per cent. per annum to live within the available income and to fund from our own resources…This has resulted in staff reductions each year—a difficult action for a busy hospital to take, but one which we continue to believe necessary given our commitment to improving the range and quality of services we provide, and the need for financial stability to avoid in-year problems. At the same time, the hospital's clinical workload continues to rise. Unlike other hospitals"— I hope that Conservative Members will pay particular heed to this—

we are not experiencing a drift of patients away from Lewisham, (reflecting the predominantly local nature of our workload) indeed we currently have the busiest A and E department and the highest proportion of emergency workload in South East London. Our frustration results from our being unable to see recognition and support for what we are trying to achieve in the context of an extremely fluid external environment. You will be well aware of the pressure Lewisham was under last winter—we have every reason to believe that this winter will be similar…Our frustration is encapsulated by the lack of a shared vision of how acute services should be shaped over the next few years…Our arguments for much-needed capital investment at Lewisham have been well supported, but there is no sense of how Commissioners will support this growing level of demand through contracts and income…We continue to believe that the service, quality and financial arrangements all point to the need to reduce the number of major…sites to three, but can understand the overwhelming lack of public confidence in this view, given the lack of recognition and support for the pressures that hospitals like Lewisham are facing even now. Those are the people who were in the front rank in the establishment of trusts. They are the true believers, not the moaning Minnies and carpers; they wanted to get on and make the new health care market work. That is what they are saying now about the position in which the acute services of south-east London's hospitals have been placed.

Much of what the Government have done in London has seriously undermined the principles of the national health service, and seriously shaken public belief in the kind of service that is being provided. A constituent of mine went, with his wife, to discuss the possible removal of a metal plate that had been inserted because of an earlier injury. They were told that that was not possible. In a letter, my constituent wrote: This has made my wife quite worried because no mention of these complications had been commented on previously. Of course one has to listen to the advice and have faith in their doctors but with all the financial and budget problems, especially at the end of the financial year, in the back of our minds we have this constant worry, is it really down to medical reasons"— or, asks my constituent, is the non-removal due to lack of finances?

That is typical of the doubts and suspicions put into the minds of patients by—[HON. MEMBERS: "You."] I was going to say, by the current disposition of the health service. Health service workers have written about it in the light of their own experience at a real hospital: real people are saying real things. If Conservative Members are too stupid to absorb that, I suggest that they go out of here more often, rather than less, and actually speak to some of those people.

Yesterday, I received a letter from my local general practice enclosing information received from the Guy's and Lewisham trust. It states: I am horrified to think that we are expected to behave in the way suggested by the Guy's and Thomas's Trust. The practice wants to display a tariff brochure in the surgery. It resembles a holiday brochure: it shows all the possible medical procedures, giving the prices and even including the wholesale rates for bulk purchasing. It also wants to place a card in local surgeries, advertising the Guy's-St. Thomas's special deal for private patients. On the back is written, Please display this notice on your patient notice board. The GP says: It does not take much imagination to realise the massive bureaucracy which is being created to run all this. I remember when the Labour Party said the Health Service was being privatised they were laughed at. If this is not going a long way towards it I don't know what is. You may rest assured these brochures will wind up in my bin. I will write and thank her.

The Government's problem with the health service in London is that, despite all the flannel and all the noise, Londoners do not believe them. The people of London realise what is happening to their NHS; they know who is responsible. They will make the Conservative party pay a heavy price for the damage it has done to some of the finest centres of medical excellence anywhere in the world.

7.55 pm

Mr. Toby Jessel (Twickenham)

I shall return in a moment to the anecdotes of the hon. Member for Lewisham, West (Mr. Dowd), which did not impress me. I wish that he—like the hon. Member for Woolwich (Mr. Austin-Walker)—had referred to the greatest danger to health in London, which without doubt is smoking. According to the Government's White Paper, "The Health of the Nation", At least 80 per cent. of lung cancer is associated with smoking, some 26,000 deaths a year. That would be nearly 3,000 in London.

On top of this, the habit kills more than twice as many people than other diseases. It has been estimated that among an average 1,000 young adults who smoke cigarettes regularly; about one will be murdered, about six will be killed on the roads, but about 250 will be killed before their time by tobacco. Despite the substantial fall in smoking prevalence over the last twenty years, smoking remains the largest single cause of preventable mortality in England.

Ms Mildred Gordon (Bow and Poplar)

The hon. Gentleman is making a very good point, but can he explain why his Government refuse to ban tobacco advertising?

Mr. Jessel

That is a matter for the whole House, and I hope that the whole House will support the private Member's Bill next month. It seems to me that in 50 or 100 years' time future generations will think that we were absolutely batty to allow this poison to go on destroying so many young lives. We know from the Royal College of Physicians that, of every cohort of 1,300 15-year-olds in any constituency of whom a quarter smoke, a third of that quarter will, at the current rate, die from smoking or smoking-related diseases. We must get a grip: this is a cross-party matter, and I hope that we shall deal with it before long.

The central point of the motion is whether London's health service cares properly for patients. So far, the debate has largely been on the producer side—about provision, money, the number of beds, buildings, institutions and how it all looks from the point of view of doctors and nurses, administrators and other national health service workers. There has been comparatively little in the debate about the consumer point of view—the point of view of patients.

What patients want, above all, is to stay alive for as long as possible. We should not mince our words about this. We all have to die sometime, but most people want above all else to delay the onset of death. Death is the great enemy, and to defer it must be the prime object of the NHS. Nothing else, such as the control of pain, is anything like so important.

In the Gilbert and Sullivan opera, "The Yeoman of the Guard", the character Fairfax, who is under sentence of death, sings: Is life a boon? If so, it must befall That Death, whene'er he call, Must call too soon. He was a young man who was awaiting execution, and sometimes the young say that they do not want to live over the age of 80. They may feel different when they are 79.

These days, thanks to better health in London and the rest of the country, far more people survive to reach old age. That is also true at the other end of the age spectrum. The infant mortality rate—the number of babies who die before they are one year old—was 11.2 per thousand in 1981. By 1991, it had dropped by one third to 7.4 per thousand. That is by any standard a substantial and significant improvement in the health of babies and in their survival rate.

At the other end of the scale, the expectation of life for a person aged 70 is 11 years for a man and 14 years for a woman, and it is going up by nearly one year every five years. Deaths from pneumonia dropped by a half from about 54,000 in 1981 to 28,000 in 1991, and that is an enormous improvement.

In 1981, the year in which we brought in the compulsory wearing of seat belts in the front seats of cars —I played an active part in that, as you may recall, Madam Deputy Speaker—there were 5,500 deaths in car accidents. By last year, that had dropped to 4,500—a drop of about 20 per cent.—despite a substantial increase in traffic in that decade.

The national health service in London, as elsewhere, has other objects—preventing pain, respite care, care in minor illnesses and so on—but the prevention of death must always be the main one.

The King's Fund report published in 1992—I have had a quick look at the report published in April, which does not in any way contradict the 1992 report—refers to the health of Londoners.

The report refers to the health of Londoners. It comes to some definite conclusions which have not been contradicted by anything that has come out since. The report says that the rate of mortality due to all causes within the capital is better than elsewhere. It also says that London districts have consistently and significantly lower levels of mortality from circulatory diseases, lung cancer, cervical cancer and motor vehicle traffic accidents. However, it also says that London districts have significantly worse records of mortality due to avoidable breast cancer and suicide. The report states that Londoners as a whole experience significantly fewer illnesses and symptoms as do residents of comparable areas, and that the overall health of Londoners is no worse—and may indeed be better—than that of people in similar parts of the country.

We all know how Opposition Members will react to such information. If they see that health is better in some way in London than in the rest of the country, they will argue that the rest of country is deprived. If they see that health in some other respects is better in the rest of the country, they will argue that London is deprived. Of course, it is impossible to bring about precise equality in the matters because there will be variations in the incidence of smoking or in the consumption of cholesterol-carrying food in different parts of the country. One is bound to get some variations.

It is established in the report that general health in London is no worse than in the rest of the country. What matters in the end is how healthy people are and what their prospects are for survival and for the avoidance of illness and pain, rather than building up the interests of professional people and institutions.

We know from the debate that the number of beds is no longer to be seen as a crucial factor in looking after any given number of people. It is little short of dishonest to make the number of beds the main yardstick.

That is partly because of the increasing amount of day care. I obtained today a comparison of day cases with all admissions at the West Middlesex university hospital—it is not in my constituency, but it serves it—which compared 1992–1993 with 1993–94. In gynaecology, 22 per cent. of cases were day cases—a figure of 666—in 1992–1993. In 1993–94, the year just ended, it had increased by a massive 32 per cent. to 54 per cent., and the number of day cases for gynaecological operations was 1,714.

I could give other examples, and I have picked the most striking one. In ear, nose and throat cases, 10 per cent. were day cases in 1992–1993. In 1993–94, they had nearly doubled to 18 per cent. An ever-increasing number of treatments require only day care, and do not require a patient to stay the night. For those treatments for which in-patient treatment is needed for acute cases, the patients often need a shorter stay than they would have needed 10, 20 or 30 years ago. A heart bypass operation will now often require a patient to spend 11 or 12 days in hospital, whereas 10 or 15 years ago the patient might have required 15 or 18 days in hospital. Smaller operations—either gynaecological ones which still require an overnight stay, varicose veins or hernias—very often entail a one-night stay in hospital, whereas a generation ago people went into hospital for three or four days. That is a major factor.

It is not just that the population of Greater London has declined by 12 to 15 per cent. in the last 30 or 40 years. That, I may say, is a secondary factor, although it is frequently cited.

I shall mention certain particular hospitals in which I am interested. The first is the Teddington Memorial hospital in my constituency, which is the smallest national health service trust hospital in the country. The amount of local support that it attracts is extraordinary. Its league of friends produced £2 million to augment the national health service provision for my constituents who use it. Kingston and Richmond, the local district health authority—the purchasing authority—has just agreed that it should provide all 49 of its beds as general practitioner beds, instead of the previous figure of 27.

Ten years ago, the hospital was going to close. I took a delegation to see the then Minister for Health, now my right hon. and learned Friend the Chancellor of the Exchequer, and he decided to intervene in the decision to close the hospital which had been made by what was then the Hounslow and Spelthorne district health authority. The hospital is now flourishing, and the support continues. its position as a trust hospital is provisional: it is on a two-year trial; we have gone slightly over the first year of that trial. I draw its success to the attention of the Minister for Health and I hope that at the end of the debate he will say something encouraging about its future.

The other national health service hospital in my constituency, St. Mary's hospital, Hampton, is a smaller community hospital. Last month, I took a delegation to see the Under-Secretary of State, my hon. Friend the Member for Bolton, West (Mr. Sackville) about that hospital, which is not being provided with the support that it needs to continue providing GP beds. Its use is to be changed to provide care for the mentally ill, with priority given to mentally ill Hampton residents. The hospital has drawn tremendous support from its league of friends and local people. Will the Minister take a last look at whether its current use could be saved, as it is cherished and has tremendous community support?

As the borough of Richmond has no general hospital, my constituents go to several different general hospitals outside the borough. I have already mentioned the West Middlesex University hospital. Some constituents go to Kingston hospital, Queen Mary's University hospital, Roehampton, Charing Cross hospital or Hammersmith—[Interruption.] I believe that all those hospitals will survive.

My constituents are intelligent enough to know that what matters is the treatment that they receive from the national health service and whether their illnesses will be cured so that they will survive and live to an old age. They see that the treatment is primarily provided by professional individuals and that the importance of buildings is secondary. I hope that in the rest of this debate, therefore, Opposition Members will show a little more appreciation for that common-sense point of view. When discussing health in London or any other part of the country, what really matters is the health of individuals who are treated by professionals.

We have made tremendous strides against waste in the national health service, but I still believe that more can be done. First, far too many people have cupboards and drawers filled with half-used bottles of medicines and pills. The British are a nation of medicine wasters. We need a change in culture and public attitude to that. The system of GPs holding budgets provides an incentive to GPs to be more careful not to prescribe wastefully. I wish to insult nobody in the medical profession: I have three doctors in my family, two of whom are GPs and I frequently argue that point with them and, in the end, they admit that I am right. Everyone knows that I am right. Too much medicine is wasted.

Secondly, too much consultants' time is wasted. A consultant orthopaedic surgeon at the West Middlesex hospital told me recently that some 20 per cent. of the patients due to consult him are what an airline would call "no shows". A monstrous amount of valuable time of consultant orthopaedic surgeons or any other doctor is wasted by patients who are too idle, careless, inconsiderate or selfish to ring up and say that they cannot come so that some other patient can be slotted in. We should analyse the extent of that wasted time and try to achieve within the national health service a system of sticks and carrots to ensure that such patients are more considerate to other people who wish to make proper use of the time of consultant doctors.

I could say much more on this subject, but I know that other hon. Members are hoping to speak. I am grateful for this opportunity to address the House on the national health service in London. Longevity is increasing, health is improving, and Opposition Members should try a little harder to see the wood from the trees.

8.14 pm

Mrs. Bridget Prentice (Lewisham, East)

I am both pleased and saddened to have an opportunity to speak in this debate on the national health service in London. I am pleased that Opposition Members have a chance to put London's case, which the Secretary of State has avoided for so long, but I am saddened that we should have to do so.

London Members could list case after case from our constituencies of people who have waited for months, if not years, for treatment, who have been returned to their homes too early, who have not been treated because of their age or who have been on waiting lists for too long because GP fundholders can jump the queue thanks to the two-tier health service. We could cite horrendous cases of people on trolleys in accident and emergency wards for hours on end, people whose coats have been used as pillows because insufficient pillows have been available and people whose families have had to provide food and drink because staff on the wards are too overworked to do so. There are examples like that every day of every week in London hospitals and Opposition Members are painfully aware of them. If they thought about it, Conservative Members, too, would be as aware. That is the state of the national health service in Europe's largest capital city. What an indictment of the Government's policies and the Secretary of State's handling of health in London.

I wish to look at the broad picture described by those who responded to the London Labour Members' inquiry into health care, and then say what is happening in my area. I shall not say how or why we conducted that inquiry, as that has been adequately covered by my hon. Friends the Members for Woolwich (Mr. Austin-Walker) and for Islington, North (Mr. Corbyn). Let me emphasise that London is not over-bedded, as both Professor Jarman and the Government's figures have pointed out. Will the Minister assure us that all hospital and bed closures will now cease so that a proper review can take place? If the Health Secretary did that, she might restore some of her seriously diminished credibility in London.

The Secretary of State made great play of funding for mentally ill provision in London, yet she totally ignored the Mental Health Commission's report, which said that there was a grave shortage of beds not only in inner cities generally but particularly in London. My hon. Friends the Members for Lewisham, West (Mr. Dowd) and for Lewisham, Deptford (Ms Ruddock) and I spoke last Friday to the chair and chief executive of Lewisham and Guy's Mental Health trust. They raised a number of concerns, the first of which related to disturbed children. They believe that they are reaching only one in 10 of the disturbed children in the local population. It does not take much imagination to work out the consequences of that. They were concerned about the serious blockages of beds and the problems that that raised and they were adamant that we must halt the reduction in the number of acute beds.

We asked those people directly whether there were enough beds for Lewisham's population and their answer was a categorical no. That has extremely serious consequences. A lack of beds means that voluntary admissions are increasingly difficult. That creates enormous problems not just for individual patients but for those who surround and support them. Lewisham and Guy's Mental Health trust said that it was forced to use private beds for people detained under the Mental Health Act 1983 and that 50 per cent. of the patients in Lewisham are detained under that Act, compared with only 7 per cent. nationally. Hither Green hospital in my constituency is part of the service that provides for those patients. Many such patients cannot get in Lewisham the in-patient treatment that they would get elsewhere in the country, so all the talk from Conservative Members about overprovision in London is simply not true.

The chief executive and the chair of the mental health trust also talked about forensic beds. They said that they had had to put nine people into private beds at a cost of £80,000 per person per year in order adequately to look after those people. Is that the best use of NHS resources in London? I think not, and they think not. The chief executive and the chair said that they needed at least 15 more beds. That is not many to ask for, but it would make an enormous difference to the quality of care provided for our constituents.

The chief executive and chair recognise, as we do, that part of the problem lies not with the Department of Health but with the Home Office, which is transferring people from the criminal justice system into the health service without transferring the funds to go with them. What negotiations has the Minister or the Secretary of State had with the Home Secretary about ensuring that those funds are forthcoming?

The Secretary of State berated us about accident and emergency units and mentioned in particular the accident and emergency unit in Lewisham and its funding. I shall return to that subject, but wish to mention a survey—conducted by the Royal College of Nursing in January on overnight stays in accident and emergency units—which produced some horrifying results. Outside London, the chances of an overnight wait were one in five, but in London, 50 per cent. of patients were likely to stay overnight in an accident and emergency unit.

The Royal College of Nursing's survey included representations from two London hospitals. The first stated: Two to eight patients stay overnight in the department every night, the waiting room has become a mini ward. Most patients wait about 24 hours for a bed. Recently, the problem has become worse due to bed closures. Another London hospital stated: Four to eight people stay in the department overnight on a regular basis. The situation has become worse over the last few months, due to bed closures. The wait for a bed can be 24 to 36 hours. Those problems are important because they have a direct effect on patients' health.

The Royal College of Nursing is concerned that waiting on trolleys in accident and emergency units will cause a deterioration in patients' health. It gives examples of the complications that arise due to pressure sores. It talks about the use on trolleys of mattresses that are not designed for long-term occupancy. It says that people who might have fallen and fractured their hip are well on the way to developing pressure sores before being admitted to an accident and emergency department, and temporary mattresses will exacerbate the problem. Such events are occurring in London hospitals day in, day out and night in, night out. I pay tribute to my hon. Friend the Member for Dulwich (Ms Jowell), who unfortunately cannot be here today as she is ill herself. She has done sterling work in studying what is happening at casualty departments throughout London's hospitals.

I shall briefly mention Lewisham and Hither Green hospitals. I shall not describe in detail the problems facing my constituents who have had to wait as operation after operation has been cancelled. I shall not go into the details of my constituent Mrs. Rew who, at 78 years of age, broke her arm and had to wait 31 hours without being told what would happen to her. She had little to eat and it was only thanks to the intervention of her daughter that any action was taken. I shall not go into detail about my constituent Mrs. Mountfield who suffered a detached retina during a cataract operation at Greenwich. Her general practitioner tried to send her to St. Mary's in Sidcup, but three weeks later she was told that she could not be treated there as she came from outside the area.

I want to nail the myth perpetrated by the Secretary of State about Lewisham's accident and emergency department. As my hon. Friend the Member for Lewisham, West said, it is the busiest accident and emergency department in south London, handling some 71,000 cases a year-40 per cent. of the total in the south-east region. The £4 million that the Secretary of State said was being invested in Lewisham's accident and emergency unit was invested only to cope with the extra expense needed as a result of the closure of other south-east London units.

Lewisham has the only 24-hour accident and emergency department for children—an important and unique provision. We must ask the Minister how Lewisham's accident and emergency department will cope when Guy's hospital closes. There is to be an expansion in capital projects at the accident and emergency unit. Where will the money come from to pay for the revenue costs of that unit? Unless the Government fund those costs, we shall have an unused, empty white elephant. What good will that be to the people of Lewisham and beyond?

How can Lewisham hospital be expected to provide the quality of care that we have come to expect when 70 staff —50 of whom are skilled and experienced nurses—are to be sacked? My hon. Friends and I met the management of Lewisham hospital last week. They told us that they were £2.5 million adrift, which was why they were sacking nurses. They told us about the accident and emergency department, but said that they did not have the revenue to fund it.

I have mentioned the unique accident and emergency provision for children. Of the nurses to be sacked, two are paediatric night staff at the accident and emergency unit. How can sacking them improve the quality of care for children in Lewisham and beyond? What will happen to the 24-hour service now? Other nurses to be sacked include 12 grade E nurses who look after the elderly and younger disabled people at Hither Green hospital. They have been told that they will be sacked, but can apply for jobs as care assistants. There is something fundamentally rotten about a system that allows that to happen.

The hon. Member for Mid-Kent (Mr. Rowe), who is no longer present, talked about what most saps morale in London hospitals. What saps morale most is being handed a redundancy notice by a hospital that cannot match its budget. We know that the system is wrong. We have spoken to the commissioning agents and asked them to talk to the Lewisham trust to prevent the redundancies. We support the nursing and support staff in their fight to save their jobs, which is why we joined the demonstration yesterday. We are fighting to save those jobs, not just because the nurses and support staff deserve to keep their jobs but because we do not believe that the people of Lewisham will benefit if the jobs disappear. On the contrary, their health care provision will become decidedly worse.

As in life, much of politics is about perception. The perception of the people of London is that the Government are incompetent and do not care about their needs or aspirations. Their perceptions are the same as those of the members of the Royal College of Nursing, who today described the Secretary of State for Health as blind and deaf to the needs of the health service. Their perceptions tell them that the Government cannot and will not look after the national health service in London. Their perceptions tell them that they can no longer trust the Government with their health service. That is why they will vote against the Conservative Government and the Conservative party next week.

8.28 pm

Mr. James Clappison (Hertsmere)

I welcome the opportunity to participate in the debate. I intend to draw the focus of the debate on to outer London health and hospital services whose voice has not been sufficiently heard so far in the debate. I particularly want to mention the outer London hospital, Barnet general hospital, which serves so many of my constituents in south Hertfordshire.

We have had a debate on inner London health services and the strategic arguments relating to them. I welcome the fact that we are having a debate about the health service in London, which comes on top of the long-running debate about inner London's hospitals and acute care in inner London. When I saw that the debate was tabled for today I thought that it was not a complete coincidence that it should take place at approximately the same time as the local government elections. My suspicions increased when the spokesman for the Opposition in today's debate was not the health spokesman, but the transport spokesman and the co-ordinator of Labour's London elections.

My suspicions were confirmed in greater force by the contribution of the hon. Member for Holborn and St. Pancras (Mr. Dobson). I was surprised by the extent to which he totally ignored all the familiar strategic arguments about the future of London's health care which were put forward in the Tomlinson report, the King's Fund report and the 18 other reports. Instead we had a ramble, familiar to connoisseurs of pre-election Labour efforts, around Labour's over-emotional and over-hyped approach to the health service.

Many of the hon. Gentleman's arguments were not ones which I have come across before in the debate. He took even my breath away when he made a comparison between the health service and the police force, because I have not seen such a comparison in any of the reports or debates. If that is the sort of grasp of strategic comparison that the hon. Gentleman has, in the highly unlikely event that—heaven forbid—he were ever to be Secretary of State for Transport, I would have to make preparations to travel from Hertfordshire to Westminster by passenger ferry. His remarks were out of this world.

I suppose that I should have been on my guard when I saw the Labour motion for today's debate. Anyone who is familiar with the debate about London's health services will know that primary care lies at its heart. Today, the Labour party managed to frame a motion for this debate which omits primary care altogether. I am pleased that the amendment proposed on behalf of the Government, for which I will willingly vote, highlights primary care. It is absolutely right that primary care should be the starting point for a debate about inner London health services.

I agreed with some of the contribution of the hon. Member for Islington, South (Mr. Corbyn) when he spoke about health status and health conditions in London. However, he did not go on to make the connection which I think that he could have made between those conditions and the state of primary care in London. That connection has been acknowledged not only in the Tomlinson report but in many of the other 18 reports released over many years.

Primary care in London lags well behind primary care in outer London and in the rest of the country. Those people who seek primary care in inner London are likely to be seen by a single general practitioner who is likely to be older, whose premises are likely to be much more inadequate than those in other parts of the country, and who is less likely to be able to offer them the same sorts of preventive measures and other forms of health care as general practitioners in other parts of the country are able to offer.

Primary health care measures such as minor surgery, screening, and immunisation for children are much less prevalent in inner London. I think that that important fact should be highlighted in this debate and the starting point of the debate should be how we will improve primary care.

The hon. Member for Woolwich (Mr. Austin-Walker), who has been assiduously following the debate, posed the question: is there any link between primary care and the use of acute services in inner London hospitals? He said that he did not think that there was a link. In his absence, I hope that he will not mind if I address the point. I asked the same question when, as a member of the Health Select Committee, I heard Sir Bernard Tomlinson give evidence. I should like to draw the attention of the House to Sir Bernard's reply to me in that hearing. He said: If primary care in London were readily accessible to more people, you would certainly relieve the intolerable strains we have witnessed in some A and E departments that are almost daily filled to overflowing. The seriousness of that is not that those that are there really for primary care cannot be dealt with adequately but that patients who really have pressing needs may have to wait a very long time to be seen. He concluded:

We do think there is a strong assumption that can be made that better primary care will deal with patients who, under circumstances of poor primary care, may well require hospital admission. There is plenty of other evidence to support Sir Bernard's contention. I invite Opposition Members to look at the consequences of the absence of proper primary community care at the other end of the admission spectrum. There is plenty of evidence that the absence of adequate and effective primary and community care delays discharge from hospital. It has been estimated that between 15 and 30 per cent. of those who occupy acute care hospital beds in inner London could be cared for in more appropriate settings if they were available.

An improvement in primary and community care must occur. Such care is a more effective use of resources and it is better treatment for the patients concerned. Inevitably, that will create a change in the pattern of provision of health services in London and will reduce the demand for acute services.

As both Professor Tomlinson and the other reports have pointed out, at the same time other factors are likely to accelerate the trend towards a decreasing demand for acute services in inner London. My hon. Friend the Member for Broxbourne (Mrs. Roe) drew on her great experience as Chairman of the Health Select Committee. She told the House about some of the visits that the Committee had made to hospitals in London and some of the technological advances Committee members had seen. I was privileged to take part in some of those visits as a member of the Committee and I agree with everything that she said about the effect that changing technology and greater efficiency will have on patients' length of stay in acute health care.

I would go perhaps even further than my hon. Friend. There is very strong reason to believe that the changes will be more pronounced in London than in the rest of the country because there is greater scope for such change in London. The King's Fund report, which has been mentioned in other contexts by Opposition Members, highlights that. The report found that such changes will affect all hospitals, not just those in London, because already the capital is tending to lag behind in terms of efficiency and so the scope for productivity gains is that much greater. This is by far the most significant factor identified by the Tomlinson report as impacting on the required number of beds in London. It also plays a key role in the report by the King's Fund. I draw the attention of the House to the flow of patients into London. Opposition Members have made some derisory comments about that flow, saying that it is part and parcel of the much-derided internal market. But we did not hear a great deal of hard evidence from them about the flows and the most effective way of treating patients and deploying resources.

I invite my right hon. Friend the Minister to consider the fact that 21 per cent. of acute care beds in inner London hospitals are occupied by patients who come to inner London from outer London and outer Thames districts for acute care. Half that 21 per cent. are going into non-special health authority hospitals for the sort of routine acute care which could be available in the outlying areas. I think that that is a misapplication of resources when the cost of treatment in London, as we have heard today, is 46 per cent. higher than it is in outer districts.

That brings me to the fate of Barnet general hospital, which is of great interest to my constituents. There has always been a very strong case for the redevelopment of Barnet general hospital and I believe that that case is made even stronger and more compelling by the fact that patients will go to outer London hospitals for routine surgery when they might otherwise have gone to inner London hospitals.

The case for Barnet general hospital is a long-established one. It goes back more than 25 years when plans were first drawn up for redevelopment of the hospital. Since then, it has become something of a saga in the health service. Those plans did not come to fruition, which caused great disappointment. It was felt that other priorities took precedence; but local people in Boreham Wood, Potters Bar and Barnet thought that progress had been made when the Health Minister wrote to Barnet community health council as follows: We are all aware of the pressing need for better hospital facilities in the Barnet area. It is the economic situation we face which prevents us remedying Barnet's particular difficulties. That Minister was David Owen, writing in 1975.

Since then, the redevelopment of Barnet hospital has been a continuing saga. Finally, last year, the Wellhouse Trust, which had become responsible for Barnet and Edgware hospitals, produced a proposal for the redevelopment of Edgware hospital, for the closure of the A and E department at Barnet and the transfer of patient services from there. The hon. Member for Holborn and St. Pancras got his facts wrong about that, incidentally.

Since then, there has been a change of heart by the Wellhouse Trust, and that has been widely welcomed in Barnet and my constituency. Fresh proposals have been introduced by the trust, involving a major redevelopment of Barnet hospital. I believe that they do justice to the health needs of the people in Barnet, in Hertfordshire and in the parts of Enfield that are also served by the hospital. All this is certainly in line with the long-term strengths of the hospital's case.

As one of the hon. Members, along with my hon. Friend the Member for Chipping Barnet (Mr. Chapman), who supported the case for Barnet's redevelopment, I might add that a crucial factor in favour of Barnet hospital has been the role played by the purchasing health authority, which did not accept the Wellhouse Trust's original proposals. I pay tribute to the role played by the South West Hertfordshire district health authority, which took soundings of local opinion, took a view of local health needs and acted accordingly.

I believe that the purchaser/provider split played a significant role in this. Indeed, I wonder whether, without it, the trust would have accepted change so readily. Strong purchasers certainly have a great deal to offer the health service.

I urge the Minister to consider the case of Barnet general hospital and the case for outer London provision. Above all, I invite him to think about the long-term strategic factors affecting the shape of health care in London. It is not an easy subject. There are many temptations for politicians to use the opportunities presented by change such as this. Today, the Opposition succumbed to those temptations. It is interesting to note that their health spokesman was banished from the Front Bench today. Could that be because he said that the status quo was no longer an option, while the rest of the Opposition still argue against change?

At Question Time today, the Leader of the Opposition came along to say that the Tomlinson report was discredited. Perhaps he and the hon. Member for Holborn and St. Pancras, who also derided change, should have consulted Labour's spokesman for health in the House of Lords, Baroness Jay, who said not long ago that nearly everyone who has looked at London's health services agrees with Sir Bernard Tomlinson's general conclusion that some rationalisation and reorganisation should occur."—[Official Report, House of Lords, 13 December 1993; Vol. 550, c. 1221.] The question is: will the Opposition listen to her? Will they listen to Sir Bernard or read any of the reports that have been drawn up?

Of course, Opposition Members are not interested in listening; they are interested in whatever advantage they can extract from manipulating opportunities before the local elections. They will, however, not gain a single vote as a result of their efforts today. They have merely damaged even more their long-term credibility as a party genuinely concerned about the health needs of Londoners and of outer Londoners.

Opposition Members have indulged in some badinage about Conservative Members who may lose their seats. The electorates of my constituency, Barnet and many other parts of outer and inner London will be unimpressed by the way the Opposition have sought to use this debate.

8.44 pm

Ms Glenda Jackson (Hampstead and Highgate)

Perhaps, in the light of the closing remarks of the hon. Member for Hertsmere (Mr. Clappison), this would be an opportune moment to introduce a voice not much heard in today's debate—that of the patient, the user of the national health service here in London.

A pensioner constituent of mine wrote about a hip operation as follows:

Admission was cancelled on December 21 1993 and on February 15 of this year. I was admitted on March 15th…At about 11 am on the next day I was given a Pre-med. When I woke up about 90 minutes later in the ward I was absolutely horrified to discover that my hip was untouched by human hand! The next day I was sent home. In response to a letter from me, the chief executive of the Royal Free hospital trust in my constituency, where this occurred, wrote: The decisions to cancel your first two admission dates on 21 December 1993 and 15 February 1994 were taken because … the Consultant Orthopaedic Surgeon had to admit other patients as emergencies from our Accident and Emergency Department. That, in essence, refutes the arguments adduced by the Conservative Members who actually took this debate seriously and did not attempt to use it purely for party political purposes.

The hon. Member for Hertsmere mentioned the King's Fund. Perhaps he missed today's report in the Evening Standard, which said that the King's Fund Institute has discovered evidence that, far from a £70 million overspend in London, London is underfunded by almost £200 million.

The one thing Londoners can be sure of is that, since the Secretary of State published her document "Making London Better", waiting lists have grown longer, proposed hospital closures have come thicker and faster, A and E units have disappeared, the number of doctors and nurses has decreased while the number of managers has increased, and, far from the capital becoming better, evidence is growing at an alarming rate to show that health provision in our city is becoming worse.

In my North East Thames region, acute hospital beds have decreased in number by 34 per cent., from 13,644 to 8,959. Department of Health figures show that in December 1993 there were 106,026 people waiting for hospital treatment, 12,805 of whom had waited more than 12 months.

Percentages and figures in thousands have become almost meaningless. My worry is that the Secretary of State in particular has lost sight of the fact that these numbers are made up of real people—a concern exacerbated when I heard today what I considered one of the most shameful performances ever by a Secretary of State at the Dispatch Box. It was shameful in its total lack of concern for the real needs of Londoners—and the most vulnerable Londoners at that.

In evidence given to the Select Committee on Health on London's health service, on Wednesday 2 March 1994, the Secretary of State asserted that among the overall objectives announced in "Making London Better" was that of preserving and enhancing London's reputation as a centre of excellence for treatment, teaching and research. As ever, Tory words are belied by Tory actions. It took a campaign organised and supported by patients, staff and hon. Members of all parties to ensure that the renal unit at the Royal Free hospital in my constituency was retained —this the hospital where the first successful kidney transplant in the world, outside the United States of America, was performed. That was despite the recommendation from the London implementation group—put in place by the Secretary of State—that it should be moved. The Royal Free is still waiting to hear whether its cancer, cardiac, paediatric and haematology units will be saved. Perhaps the Minister will answer that point directly tonight. Those threats are particular to the hospital in my constituency, but there are equivalent threats hanging over all London hospitals and the ensuing anxiety and drop in morale is felt not only by the doctors, nurses and ancillary staff, who give far more than a fair day's work for the far from fair day's pay allowed them by the Government, but also by patients.

In response to a question from the hon. Member for Belfast, South (Rev. Martin Smyth) during the same Select Committee debate on London's health, the Secretary of State said: There is no doubt at all in the NHS all emergency and serious cases must be seen immediately indeed 47 per cent. of the work in London is admitted at once". Setting aside the fact that presumably 53 per cent. of the work is not, that reply would be no comfort to my constituent, who is 71 years old and, having had an operation cancelled three times, wrote this to the Secretary of State:

It seems likely I shall predecease my hypothetical next appointment. Is this perhaps what your department means by market forces? The letter was passed to Charles Marshall, chief executive of the UCH Middlesex hospitals, to whom my constituent had also written direct asking: Are there beds or not? Ministers seem to believe that the number of beds is excessive. If so, why are so many people still awaiting treatment? Mr. Marshall's reply was: Whether there are enough beds or not is … a moot point. We are of course delighted to provide as much care and open as many beds as the district health authorities wish to purchase. They, however, are subject to cash limits and are unable to authorise us simply to respond to demand. The result is that there is an element of rationing in the system. That is rationing care, not on the basis of need but on the basis of health authority purchasing power. The Government's initial error in pursuing the policy of an internal market for health provision is patently failing to deliver—not only to the individual patient, but to that patient's family.

A mother in my constituency had her operation cancelled. The cancellation of that operation affected not only her but her husband and her two young sons. Her operation was finally rescheduled only to be cancelled on the day she was admitted. Her husband works as a waiter and has no time off with pay, but had managed to agree unpaid leave to look after the boys and his wife during the period of bed rest that doctors said was vital for her after the operation. I am happy to say that my constituent has now had her operation.

Many health care professionals in my constituency responded to the Labour party survey on the health service in London, including the professors of preventive medicine at Bart's, of leukaemia biology at Hammersmith, of thoracic medicine at the Royal Brompton and of surgery at the Royal Marsden, the consultant physician in intensive therapy at Bart's, a consultant at the Elizabeth Garrett Anderson hospital, and several local general practitioners, including the chair of the Hampstead GPs forum. Those GPs, doctors and consultants to a person concurred with Michael Laurence, president of the orthopaedic section of the Royal Society of Medicine, when he said:

It must be generally appreciated that a national health service is precisely what the word means, a service—not a business. It requires a communal decision by a population to do the best for every member of that population. I should like to read a short paragraph from a letter from one of my constituents who is a doctor:

I feel now much as the ancient Romans must have felt as the vandals, who understood little of the culture of the city, rampaged through, leaving much destruction in their wake. The aim of the NHS was, and I hope will be, to treat the sick when necessary … My grandfather, who was a general practitioner in Liverpool at the introduction of the NHS, thereafter refused to treat private patients in case they thought they were getting a better deal. What a change all those of us who can remember the NHS being introduced have lived to see.

One of my constituents reminded me just how significant the creation of the NHS was for the vast majority of people in Britain. "You cannot imagine, Miss Jackson", she said, What it was like before when you had to wait to guess how ill your child was before you called the doctor because you were worried about his bill. The NHS lifted that worry and the fear that it will return makes those of us in London fight so hard for what we still have.

In her shameful speech, the Secretary of State referred to issues in local elections as though they were not part and parcel of the struggle that is taking place in London to preserve the basics principles and tenets of the NHS.

London needs its hospitals, its general practices and its primary care, but good health for London requires more than that. Londoners require a home that is warm and dry and a job to pay for decent, nourishing food; a job that can pay for warmth and for the prescription charges that the Government have raised so often since coming to office. They need a job that can pay for eye tests, spectacles, dental check-ups and treatments; a job that is carried out in conditions that do not in themselves endanger health. Our older citizens need a pension that does not force them to make a choice between food or fuel and an environment that is not hazardous to health, causing all manner of chest complaints.

As our capital city, London has the problems that face Britain but on a larger scale. Londoners do not suffer from different medical conditions from citizens in the rest of Britain. They do not need different operations or different doctors, nurses or anaesthetists. The high standard of health care and the jobs and homes that Londoners need and deserve are vital, too, for those others in cities and towns across the country. To provide those things for Londoners, they will have to be provided for all in Britain. I regret that they will not be provided by the present Government.

In February this year, I wrote again to my 72-year-old constituent who had been in correspondence with the Secretary of State for Health to ask whether he would like to contribute to the Labour party's health survey. A few days later, I received the following reply:

You sent your questionnaire to my husband but he was not well enough to respond and he has in fact died early this morning in Edenhall Marie Curie Centre, Lyndhurst Gardens. While he was there his consultant discussed it with him and took a photocopy. This is enclosed here and filled in by his doctor. It also represents my husband's views and mine. The subject is too serious for us to ignore". How many other institutions in this country are so admired, revered and wanted that a widow would take the trouble to write to her Member of Parliament in its defence on the same day as her husband died? If the state of the NHS in London is too serious for her to ignore, the Government have no excuse for their behaviour, for the scandalous scythe they have wielded, and are still wielding, through London's health service.

8.57 pm

Mr. David Congdon (Croydon, North-East)

Anyone listening to the speech of the hon. Member for Hampstead and Highgate (Ms Jackson) or to the speeches of many other Opposition Members might find it easy to forget that the national health service is spending more than £100 million a day and is treating 8 million patients a year in hospital—1 million more than in 1990–91.

All that the Opposition can do is trot out examples of individual patients being treated badly. No hon. Member wants to see people getting less than good-quality care from the health service, but why do Opposition Members fail to quote the many excellent examples of good care that occur in the capital day in and day out? It is all too easy to find the odd bad example here and there and to forget the good ones. Even the hon. Member for Dulwich (Ms Jowell), who was unfortunately in hospital recently, had to say that she had been given good care. But she could not resist the temptation to carp about other aspects of the national health service.

As a London Member of Parliament, I am particularly interested in health issues, including the funding for health care in London. Despite the fact that some Opposition Members have sought to muddy the waters, it is beyond doubt that massive excess resources are put into the NHS in inner London. Available information shows that the expenditure in inner London is £603 per person, compared with £415 in outer London. Surely those figures themselves demonstrate the need to consider some change.

Other hon. Members have referred to general practice or primary care services and have pointed out that London does comparatively badly, with a per capita expenditure of £124 compared with £132 elsewhere. It is for those reasons that we need change in London. As my hon. Friend the Member for Hertsmere (Mr. Clappison) has pointed out, successive reports have shown that London has too much money tied up in expensive teaching and specialist hospitals. The pressures for change cannot be resisted any longer.

Even The Guardian—not a hotbed of Toryism—had to comment back in January 1993: Similar ideas in 20 reports going back over 100 years have been aired. Successive Labour Governments"— that is a long time ago— have unsuccessfully pursued similar goals since the 1968 Royal Commission concluded that London's medical schools were too fragmented and isolated.…Only the ideologically blind"— that must be a reference to Opposition Members— are refusing to recognise the truth, set out last year in 12 volumes of research by the King's Fund, that London's health facilities do need to change and the present surplus cannot be allowed to continue. It is against that background that this debate should be taking place.

The pressures for change, which have existed for a very long time, are compounded by the very significant improvements in surgery techniques, which have led to much greater use of day surgery. My hon. Friend the Member for Broxbourne (Mrs. Roe) referred to the situation in her area. Many procedures are now possible without invasive surgery. That has led to much reduced lengths of stay in hospitals in London and elsewhere.

Another very good trend, as part of the health reforms, is that more people can be treated near their homes.

All those factors show that fewer beds are needed. Opposition Members will rightly point out that there does not appear to be a surplus in London. It is true that there are problems in some parts of London. It can be difficult to get patients into some hospitals. Indeed, the less well-developed primary care is part of the difficulty, and we must strive to provide a solution. As my hon. Friend the Member for Hertsmere said, people go to accident and emergency departments when they could see the local GP.

Hospital beds are also clogged up with people waiting to be discharged. All that puts excess pressure on beds and demonstrates that we must get the balance right in London.

I congratulate the Secretary of State on taking courageous steps in terms of strategy. Because of the problems in the relationship between primary and secondary care, it is right to proceed with caution and to remember some of the warnings in the Tomlinson and King's Fund reports to the effect that changes must be implemented over a reasonable time scale.

I want to look briefly at the issue of resources for health care in London. I accept the argument that London should probably expect to have a higher than pro rata share of resources because of increased pressures there. However, it is hard to argue that London should consume 20 per cent. of resources for 15 per cent. of the population.

Recently, I was very disconcerted when the Evening Standard—no friend of the health service in London, so far as I can see—decided to leap with glee on the answer to a parliamentary question from the hon. Member for Dulwich, which appeared to show that London was not being over-funded. The reply is to be found at column 72 of Hansard of 12 April. But the paper did not look at the answer in sufficient detail. It should have looked at note 2, which clearly states that that excluded spending on London's postgraduate special health authorities, which consume an enormous amount of money. I was concerned about the information, and my hon. Friend the Member for Worcester (Mr. Luff) and I tabled further questions to the Secretary of State for Health. We wanted to be clear about the real funding, and it was shown that another £50 a head should be added to the London figures.

Perhaps even more significant was the fact that earlier tables did not show the split between inner and outer London. That is crucial and those figures, which are contained in Hansard of 21 April, clearly show that inner London funding is 56 per cent. higher than the national average. Who could argue that that can be justified? I cannot say exactly what the figure should be, but 56 per cent. seems excessive, particularly when the figure for outer London is only 8 per cent. above the national average. That is important in terms of resources and, as mine is an outer-London constituency, I am especially interested in those percentages.

In making a judgment about resources, we also need to look at the needs of London. We know that much money is tied up in the teaching hospitals and that costs are higher in London. Like other hon. Members, I should like to draw attention to the social deprivation in parts of London.

The important Tomlinson report suggested that the number of beds in London could be reduced over a five to 10-year period by between 2,000 and 2,500 and that, at the same time, resources could be shifted to primary care. That process was started by the Secretary of State who rightly made £85 million available this year for investment in primary care in London.

Beds are a crucial part of the equation. I am loth to open the issue of beds because I know that Opposition Members are obsessed with it and that beds are not the best indicator. However, the record needs to be put straight, because there is much misunderstanding. Over the past 10 years, we have succeeded in significantly reducing the number of beds in the national health service while managing to treat many more patients. Therefore, beds are not the crucial factor.

Tomlinson drew heavily on the King's Fund report entitled "London Health Care in the Year 2010" which was published in 1992. Page 47 of the report details the number of beds per 10,000 residents and clearly shows that London is over-bedded compared with England. It also showed that, compared with similar cities, London was not as over-bedded as people believed. That seemed to be a great revelation to the Evening Standard and Opposition Members.

London has 43.6 beds in inner deprived areas per 10,000 of population compared with 41.6 beds in comparable British cities. That shows that there are problems in some of those other cities that will need to be addressed. Crucially, London's 43.6 beds compare with 25.4 nationally and that cannot be ignored.

Mr. Tracey

My hon. Friend has mentioned the commentary on London's hospitals by the Evening Standard. We all respect that newspaper, but does my hon. Friend agree that it should have done its homework a little better? I have a slight worry, which no doubt is shared by other hon. Members, that perhaps some of the Evening Standard comments on this critical matter have been rather misleading to Londoners.

Mr. Congdon

One of the problems is that many people have tried to rubbish the Tomlinson report by saying that they have found new information. There is no new information: it is all in the excellent report by the King's Fund. That was why I was somewhat surprised by the document which I received yesterday called, "London, the Key Facts" which is not as well produced. It is a much briefer document, but even that document says that inner London has 50 per cent. more beds per capita of resident population than England as a whole. Therefore, there should not be a problem over the issue of beds, but some people do not seem to understand the situation. The King's Fund suggested that London could see a reduction of about 5,000 beds. The Government have not proposed that. They have proposed the lower end of the range and that is right and proper.

Hon. Members might ask how those figures are derived. They are derived from all sorts of things such as patient flows and improvements in day surgery. We know that more people can be treated on a day basis, so that fewer people need to be treated for longer in hospital. In addition, the length of stay in London teaching hospitals is 15 per cent. higher than in provincial teaching hospitals. Even more crucial and revealing is that if inner London hospitals could achieve the level of performance of hospitals elsewhere in the country, London could make do with 2,740 fewer beds. That is not my figure; it is the figure from the King's Fund report.

Therefore, I conclude that London can make do with fewer beds. But it is important to ensure that that is only done in line with improvements in primary care and by monitoring carefully the pressures on health services in London.

Another crucial aspect of health services in London is the funding formula. It is difficult to devise a sensible formula for funding. There have been various formulae over the years. My area does not seem to benefit from any funding formula, so I would welcome something different.

It is difficult to achieve some of the changes in London while resources are being moved away from London, particularly in the various Thames regions. That needs to be looked at carefully. It is not clear exactly what is happening in each district health authority in London in terms of funding. The situation is confused by fundholders using money to purchase services. But we should be cautious about moving funding away from London at the same time as we are trying to implement the much-needed reforms.

The funding formula has to be considered in order properly to take into account social deprivation. I welcome the fact that "The Health of the Nation" sets targets. I believe that they will clearly show the differences in quality of health in different parts of the country, and that information should be used to drive the funding of individual health authorities.

There is no doubt, when one talks to health authority representatives, as the Select Committee on Health has done, that health authorities outside London do not face the same problems as London health authorities, particularly those in inner London, and particularly, as has been mentioned, in terms of the mentally ill. There is no doubt that more needs to be spent and has to be spent in inner city areas than in some rural areas on the mentally ill and their needs. I hope that when my right hon. Friend the Minister for Health replies he will consider formula funding in terms of London.

The health reforms have achieved a great deal. The internal market is leading to services being provided more closely according to need, which, in turn, is leading to benefits in outer London as well as in areas further away from London.

I am also convinced that the other reforms concerning fund holders are leading to massive and valuable change in the health service. I urge hon. Members to read the minutes of the Select Committee's meeting last night with fundholders when they are published. They show where the dynamic in the system is leading to real improvements in primary care, improvements in the services provided in doctors' surgeries and improvements in services provided across district health authorities, not leading to the sort of two-tier service that Opposition Members allege exists, but improving the service to all patients.

I congratulate the Government on those reforms and I also support the desire to ensure that we implement the proposals in the Tomlinson report sensibly. My only concern is that we ensure that we implement them at a pace commensurate with the improvement in primary care, to ensure that the services can take the strain of that change, because any change is difficult.

It is not an option in my view, as Opposition Members, especially the Liberal Democrats, say, to hold fire and not to do anything at the moment. The issue has been fudged for far too long. That is why residents of inner London do not get as good a deal in health services as they deserve. We need to get on with it and I congratulate the Government on their courage in doing so.

9.15 pm

Mr. Nigel Spearing (Newham, South)

There is one thing that the hon. Member for Croydon, North-East (Mr. Congdon) said on which there is agreement across the House: there is some need for change in the health service in London. What we disagree about is what that change should be and the fundamental levels on which it should be founded. I shall return to that major division at the end of my speech.

I wish to devote most of what I have to say in about five minutes to the ambulance service. The performance of that service is clearly visible. The patients charter says that, within eight minutes, 50 per cent. of calls should be answered and within 14 minutes, the figure should be 95 per cent. Everybody in London knows that that is not true of London.

I presented a petition to the House on that subject as long ago as 7 December 1990. Even before the dispute about that answering time, the figures began to drop. For many years before 1988, 90 per cent. of calls were answered in 14 minutes, and ever since then the figure has dived to 63 per cent. and has not changed in the past two years. That has occurred because the funds were not demand-led by patients in the street or by emergencies at home.

A written answer from the Under-Secretary of State for Health said that the managers must provide services within the resources allocated".—[Official Report, 3 March 1993; Vol. 220, c. 172] In other words, it was top-sliced on an abstract figure. Of course, those providers are not as accountable as they used to be under local government.

The Secretary of State, who I am sorry to say is not here, made a very long, three-times-round-the-course, speech. I pressed the Chair during her speech, for which I offer a partial apology, but, if I may so, the right hon. Lady was not even competent enough to tell hon. Members whether she was giving way. If she were able to tell hon. Members, I would sit down. I had to intervene, because there was no sign from her.

Several months before the breakdown of the London ambulance service, I warned the Secretary of State to consider it. I warned her in an official letter delivered in an unconventional way. I did that because I did not have any faith that the private office would let her see it. The right hon. Lady made partial reference to that letter in her speech.

The improvements did not come, so, as she said, £14 million is now allocated to the London ambulance service with the objective, according to a reply on 11 January, of putting 15 per cent. more vehicles on the road. Is 15 per cent. enough? The Government may not achieve their calculated increase, but even if they did, is it enough? The difference between 63 per cent.—

Lady Olga Maitland

rose—

Mr. Spearing

I am sorry, but I cannot give way. The hon. Lady knows very well that she is not very happy in Parliament. I shall not give way to her, for reasons that she knows very well, quite apart from the lack of time.

There is a limit of 95 per cent. and 63 per cent—[HON. MEMBERS: "Why not give way?"] I am not going to waste time explaining. At the moment, 63 per cent. of calls are answered in 14 minutes, and that rate needs to increase by 50 per cent. How can 15 per cent. more vehicles on the road provide an increase of 50 per cent? Other factors might help, but it will not bridge that gap. I regret to say that that £14 million is probably not enough. The basis of our problems in the health service is that the Government have chosen the wrong method of rationalisation, or providing what they call "value for money".

We have competition among the hospitals of east London. Newham general hospital is now a trust and could go bankrupt. It is in competition with other hospitals in London. It has to keep afloat by competition. Is that how one keeps a hospital afloat? GPs in east London are now accountable to, or are run by, a new-fangled organisation called the City and East London family and community health services, or CELFACHS—not a happy acronym. It is now a trust. Is it right that it is not accountable to local people, as the old family practitioner committees were? At least they were under some local authority elected and accountable management.

Are competition, profit-making, surpluses and statistics, about which we heard much from the hon. Member for Croydon, North-East (Mr. Congdon), the right way to run a health service? No, because it is competition.

I close on the note on which I started and I tell the hon. Gentleman and all Conservative Members why: fundamentally, it is not, as I have challenged hon. Members who represent London constituencies to argue, based on the Christian principles on which both the health service and a good deal of public life was originally based. Why? Because it makes a commodity of the difference between a body needing medical attention and advice and one that does not. Can we reduce that difference to a commodity? No, we cannot and should not, because if we do, we deny the humanity of us all.

Mr. Tracey

On a point of order, Madam Deputy Speaker. I trust that, as a courtesy to the House, the hon. Member for Bristol, South (Ms Primarolo) might like to explain the whereabouts of the hon. Member for Sheffield, Brightside (Mr. Blunkett), the Opposition spokesman on health. I think that the Labour party has rather demeaned—

Madam Deputy Speaker (Dame Janet Fookes)

Order. That is not a matter for the Chair, as the hon. Gentleman well knows.

9.21 pm

Ms Dawn Primarolo (Bristol, South)

The debate has ranged over a large area and involved the rewriting of history, and the reinterpretation of many reports to support the Government's policy as it currently exists. I should remind the House that, originally, the reforms were introduced by the then Prime Minister, now Baroness Thatcher, to reduce health expenditure. When they were introduced, the then Secretary of State for Health said: Next year…we propose to reform the NHS: the coming winter will end the last year of an entirely unreformed service. The winter of next year will not be dominated by cancelled operations, closed wards and cuts in services".—[Official Report, 11 January 1990; Vol. 164, c. 1124.] He should have added, because it would dominate every day, every week, every month in every year of the reforms.

In that period, we have seen massive bed closures, problems in our health service, not only in London but in Birmingham, Manchester, Bristol and across this country. The Government claimed that the health service in London needed to be reformed because it was overfunded. Indeed, we have heard that repeated today. London got more, it was said, than its fair share of resources. Change was inevitable not because the health service needed to change; it was inevitable because it was to be cash-driven by a reformed service and a desire to transfer resources out of London.

The figure trotted out regularly was that London had 20 per cent. of the resources and only 15 per cent. of the population and therefore cuts must follow. I recommend to hon. Members that the best way to measure the expenditure in London is to go to the regional health authorities and ask them for the allocations in budget for each of the district health authorities that make up the four regions that converge in London for 1994–95. What they will find is that London's allocation of the national cake is 15.4 per cent. of the total budget. According to the figures, London is funded 15 per cent., not 20 per cent.

In contributing to the debate, my hon. Friends the Members for Woolwich (Mr. Austin-Walker), for Islington, North (Mr. Corbyn), for Newham, South (Mr. Spearing), for Lewisham, West (Mr. Dowd), for Lewisham, East (Mrs. Prentice) and for Hampstead and Highgate (Ms Jackson) have catalogued the feelings of their constituents, their experiences of health care in London and their disbelief at the Government's presentation of their reality.

They cannot understand why London is supposedly over-bedded, yet they cannot get hospital beds. If London is over-bedded, they cannot understand why their hospitals are going bankrupt. They cannot understand why, when the Government claim to be investing in primary care, their services continue to decline, not improve. They cannot understand why, despite what the Government say, their ambulance service is not reaching the national targets for arriving when called out on a 999 call.

There has been much discussion about the King's Fund. When we look at the reports, whether they be the Tomlinson report, the first King's Fund report, the second King's Fund report, or the second of the two reports produced in the past week, we must look at the context in which they were drafted.

Tomlinson was told to take as given a reduction in expenditure—that is, because London is overfunded—to take as given that London is over-bedded and to take as given an internal market that will further reduce expenditure in London and then to produce a plan for London's services. The Tomlinson report specifically excluded a health needs assessment on the population of London—Tomlinson was specifically required to exclude that.

The new evidence today from the King's Fund suggests that London is underfunded to the tune of £200 million in 1993–94. If the Government hold the King's Fund in such high regard, as they claimed today, what they should do is not pick and choose among the King's Fund reports they agree with, but look in detail at the evidence that is being produced.

Newly emerging evidence suggests that the presently weighted capitation targets underestimate the needs of London. London is Europe's largest city. Seven million people live in Greater London, and a further 4.3 million people across the south-east of England depend on its services. Inner London has lost acute beds faster than elsewhere, and its residents in many parts are being told that they simply will not have proper cover.

Take the 1 million residents in north-east London who will not receive cover from the national health service for anything except the following four categories: emergency admissions; urgent hospital admissions; people waiting more than 18 months; and obstetrics cases. Those will be the only national health services offered to 1 million Londoners in the north-east of the city. It is simply not good enough.

Lady Olga Maitland

rose—

Ms Primarolo

With respect, it has been a long debate, and both the Minister and I want to make our case. I will not give way at this stage to the hon. Lady.

The needs of London are becoming greater. The incidence of premature mortality is much higher in inner London than in the rest of the country, as is that of neonatal mortality. Inner London has four times the national proportion of people from ethnic minority groups, who have special health needs that we should respect and provide for. Inner London has higher unemployment rates, and London as a whole has a much higher incidence of overcrowding and households that lack basic amenities.

There have been massive hospital closures in London. One in five accident and emergency units have closed, with no replacements. Now the Government are turning on the hospitals. For example, the Queen Elizabeth hospital for children in Hackney is to be closed. It is in the most deprived area in the country, covering Hackney, Newham and Tower Hamlets.

Its 107 beds are to be halved and will be split between two nearby hospitals, destroying one of only two hospitals for children in London, all because of a supposed shortfall of £20 million which is needed to upgrade the building. Incidentally, it is worth noting that charitable income for the other branch of the Queen Elizabeth hospital—Great Ormond Street—is more than £20 million and could cover the shortfall.

Overseas private work generated at Great Ormond Street could do a great deal to support the other hospital, but no, the Government intend to do worse. By the end of this century—within six years—they intend to halve the number of paediatric beds in the city.

Much has been said about general practitioners' premises in inner London. In 1982, 15 per cent. of GP premises were below national standards, but by 1992 the Tomlinson report found that the situation had deteriorated further, and that 46 per cent. of GPs' surgeries were substandard. That is during this Government's stewardship.

What about investment in primary care? What is the result of all the money that the Government have been putting in? There are 2 per cent. fewer GPs, 5 per cent. fewer health visitors, 11 per cent. fewer district nurses, but there are 32 per cent. more managers. That shows the Government's priority and the system that they want to operate.

Let no one say—not even the Minister—that we do not have a two-tier health service. I shall give him an example —a phone call today—[Interruption.] This is not funny. A one-stop breast cancer clinic at Charing Cross hospital was telephoned today about a referral. The hospital wanted to know whether the patient was from a fundholding GP and therefore whether she would be given priority. The answer was, "I believe so." I suppose that the Minister would deny that that happened, and that that person could not get any treatment in the clinic at this time.

On 25 April, in an exercise called "Casualty Watch", 58 Londoners were found facing long delays in the casualty departments of 13 leading hospitals. There were not enough beds to put the people from casualty in.

Let us know the truth about London's vanishing beds. In 1982, London's health districts had 26,297 acute hospital beds, but by 1990 the number had dropped by almost 7,000. Now London has 17,181 acute beds.

The numbers on waiting lists are soaring. Londoners are waiting longer and in greater numbers. There is less care for the elderly because some hospitals have gone and others are threatened with closure.

Londoners are being told that their hospitals have too much money, when the reverse is true. London's ambulance service is not responding to Londoners' needs.

But not only inner London hospitals are suffering. In Kingston, which was mentioned earlier, 22 beds have been closed by what we have been told is a flagship trust, because it has not enough money. As I have said, in nine months waiting lists in Redbridge have risen by more than 100 per cent; yet the Government constantly tell us that everything is all right.

A patient from Acton who was referred to the Eastman dental hospital was refused an appointment on the following basis: I regret that we are unable to offer a consultation appointment as requested. We are now receiving more of this type of referral than we have resources to see and under our current funding arrangements the only effect of accepting them all would be to run up ever increasing waiting lists. This would be frustrating for everyone concerned"— particularly the Government— and goes against the thrust of the Patient's Charter, established by the Government. To ensure compliance with the patients charter, people are being denied appointments in the first place.

Throughout the time in which the number of beds has been falling, the money available has been falling as well. What has been happening in the private sector in London? If beds are not needed, there should be no increase in the private sector, either; but between 1979 and 1983, there was a 41 per cent. increase in the number of private beds.

The Government tell us that beds are not needed. Why are people prepared to pay for them privately, when they are denied them in the national health service? Because they need them, that is why. During the same period, the astronomical salaries of bureaucrats rose by 110 per cent. —money for patient care that could have been spent elsewhere.

What do Londoners say about all this? What has the King's Fund established? It seems to be trendy to ask Londoners what they think after the health service has been destroyed rather than before, because the Government do not consult; but what do patients say? They say this: The National Health Service should continue to provide comprehensive healthcare for all Londoners as a right with access irrespective of the individual's financial resources or economic status. We want to see more money, not less, going into quality care in London.

Whilst recognising a limited…role for private health care, NHS resources of equipment, trained personnel and in-patient facilities should be for the exclusive use of the public health sector"— national health service patients, not the private sector. There should be well-resourced hospitals: Primary care…should be resourced to offer an expanded range of services". Discrimination should be eradicated. Complementary therapies should be brought into the national health service. Health promotion and education need to be on a wider basis, recognising that poverty, poor housing and inadequate access to community-based services are crucially linked to people's health.

The Government have completely ignored those criteria when aiming for the targets identified in "The Health of the Nation". They have consistently said that we oppose change, but that is not true; what we oppose is change for the sake of change, or change that is driven by market forces, commercialisation and privatisation. We believe that change should be based on the health needs of Londoners, not on a market philosophy.

The Government have got it wrong. They are presiding over chaos in London, and Londoners know it, even if the Government do not. What we want, and what Londoners want, is a regional health authority for London, planning for London; a moratorium on closures; a planning structure that meets those needs; and management of change not through the vagaries of the market but planned to meet the needs of the population of London. I urge my hon. Friends to vote for the motion.

9.39 pm

The Minister for Health (Dr. Brian Mawhinney)

The hon. Member for Bristol, South (Ms Primarolo) finished her speech by saying that the Labour party was not against change. I must say at the end of what has been a long, and occasionally acrimonious, debate that there is not a shred of evidence to substantiate that claim.

The hon. Lady and her hon. Friends said all afternoon that they were against this change, that change and the other change. Not once—not from the hon. Member for Holborn and St. Pancras (Mr. Dobson), to whom I shall return later, the hon. Lady or any of her hon. Friends—did we hear from Labour Members what changes they were in favour of.

We know that the hon. Lady wants a moratorium; in other words, she wants to add to the uncertainty and confusion of London's health care. We know that she wants a regional tier and planned health care. That came within 30 seconds of her being rude about the increased number of planners, managers, administrators, bureaucrats and all the other hard-working members of the national health service around whom she laid her tongue this evening.

The truth is that the Labour party is against change. However, nearly everyone who has looked at London's health service agrees with Sir Bernard Tomlinson's general conclusion that some rationalisation and reorganisation should occur. That was the Labour party's position as enunciated by its spokesman in the other place. My hon. Friend the Member for Hertsmere (Mr. Clappison) drew attention to that in what I thought was an excellent speech.

London's heath services may have had a glorious past but their quality in the future depends on our willingness to face up to difficult choices now. That was said by Professor Bosanquet, professor of health policy at St. Mary's medical school and Imperial college.

The balance of health and social care in the capital is not appropriate to the needs of Londoners. However, adjusting the balance will inevitably take time. The Secretary of State has shown great courage in making people face up to the need for change. Now the task is to work through these changes on the ground, building up good alternatives that are affordable, that work, and that make a better framework for the long term. That was said by the chief executive of the King's Fund.

When the Labour party says that it is not in favour of change, it finds itself isolated not just from the Government —its normal expectation—but from its own Front Bench in the other place and from experts whose disinterested observation and input in the health scene in London is beyond the contradiction of anyone—except someone like the hon. Member for Holborn and St. Pancras.

Mr. Dobson

Will the Minister give way?

Dr. Mawhinney

I will, but later. The hon. Gentleman may wish to intervene later.

I am glad that the hon. Member for Southwark and Bermondsey (Mr. Hughes) took part in the debate. His colleague who normally speaks on health matters—the hon. Member for Rochdale (Ms Lynne) keeps telling us airily-fairily that his party would spend more money on health. I was grateful that the hon. Member for Southwark and Bermondsey identified 5p in the pound as a reasonable increase in taxation, which he thinks should be devoted to improving health care.

Mr. Simon Hughes

indicated dissent.

Dr. Mawhinney

If the hon. Gentleman shakes his head in amazement, I invite him to look at the Hansard record of his speech. That is 5p in the pound for health, and at least 1p in the pound for education. It was worth having the debate so that people in the south, the south-west, London and the rest of the country who might be tempted to listen to the siren multiple voices of the Liberal Democrats next week will understand that, when the party puts forward a health policy, it carries a tag of 5p in the pound extra in taxation.

The real problem about the hon. Gentleman's speech was that he ducked the point which, I hope that he agrees, I put carefully, gently and thoughtfully. I asked the hon. Gentleman what should happen in the face of the evidence that £18 million and rising is going into the Guy's and St. Thomas's trust and the clinical incoherence testified by the clinicians on both sites, and he ducked the question.

Mr. Simon Hughes

I can deal with both points. First, the record will show that the 5p in the pound related not to party policy but to opinion poll evidence of what a significant proportion of the electorate is willing to spend. Some 83 per cent. of the electorate believe that more money should be spent on the health service. Secondly, on Guy's and investment, the Minister knows perfectly well that £18 million compares with the £150 million being spent on Sir Philip Harris house. He knows that the view in both hospitals is that the services provided will not fit on one site and that a rational disposition of services across two sites is possible if only the Minister would listen to advice.

Dr. Mawhinney

That is not what the clinicians said to me. I speak with some authority because I was the person to whom they spoke. When I spoke to the clinicians arid the trust, they told me that it was possible to put all the acute services on the St. Thomas's site. I have seen with my own eyes how that can be done. On the hon. Gentleman's first point, he rolled his tongue so lovingly around that 5p in the pound extra taxation that no one who heard him doubted the message that he was trying to convey to the public.

I agreed with my hon. Friend the Member for Croydon, North-East (Mr. Congdon) when he asked, in another excellent speech, why Labour Members never mentioned the good things that happen in the health service. It was no coincidence that he spoke on the back of what we have now come to accept as the traditional whine by the hon. Member for Hampstead and Highgate (Ms Jackson). She quoted from four constituents' letters. That leaves 40,570 in-patients and day-case patients and 194,883 out-patients at the Royal Free, none of whom she discussed because she, I, the Royal Free, the House, London and the country know that the hon. Lady likes to try to make the abnormal and the singular appear normal.

As the hon. Lady represents one of the most successful trusts in London, I should have been more impressed if she had felt able to give it some credit for the 7.6 per cent. increase in in-patient and day cases and 9.3 per cent. increase in out-patient cases which that hospital managed to achieve last year.

Ms Glenda Jackson

Will the Minister give way?

Dr. Mawhinney

No I shall not.

Ms Jackson

rose—

Dr. Mawhinney

I am quite clear that I shall not give way.

My hon. Friend the Member for Broxbourne (Mrs. Roe) made a telling point when she said that people were moving from inner to outer London. People in outer London, too, want local services. In a somewhat deriding way, the hon. Member for Southwark and Bermondsey said that people in London would not want to travel to Brighton for cardiac services. Typically, he failed to mention that people in Brighton do not want to travel to London when they can have local services. That is the point at issue.

My hon. Friend the Member for Broxbourne was right when she said that the issue was not the number of beds, which should not be used as a measure of the quality of care. I shall not bore the House with statistics, but I shall give one. During the 1980s, the average length of stay in a hospital bed dropped from about 10 days to about six days. When we add to that the increase in day surgery and the other factors that my hon. Friends made clear in their speeches, the truth is that beds have become an increasingly meaningless way of judging the performance of the health service.

The hon. Member for Holborn and St. Pancras did not even know that the number of beds is dropping in all the countries of the Organisation for Economic Co-operation and Development—we are not running all those countries. The number is dropping all over the developed world because the medical profession is finding new, better and more convenient ways of treating patients. Yes, there has been a decrease in the number of beds. There has been an increase during the same period—the past 10 years—of 53 per cent. in the number of patients treated in London. There has been an increase of 208 per cent. in the past 10 years of the number of patients in London who have had day-case surgery. The hon. Member for Bristol, South was wrong on a number of counts. She was incorrect when she said that waiting times were increasing. They have dropped by 36 per cent. since December 1991, when we introduced the criterion of the 12-month wait.

I reaffirm the pledge that Ministers have given on many occasions that accident and emergency units do not and will not close until adequate and appropriate alternative arrangements are put in place. As one of my hon. Friends made clear, it is true that about 50 per cent. of the usage of accident and emergency services in London is inappropriate. By "inappropriate" I mean that in any other part of the country those patients would have gone to a general practitioner. That problem must be resolved.

My right hon. Friend the Secretary of State recently asked the chief executive of the national health service to reinforce to the whole of the service that it was unacceptable for people to have long waits on trolleys—a common point across the Floor of the House. Opposition Members take a few cases and try to make it appear that they represent the health service, which is not what Conservative Members do.

In the past year, there were 840,000 accident and emergency cases in the 17 accident and emergency units in London. While I do not accept that any patient should get anything other than the best treatment, I deplore the Opposition's attempts to take a small handful of cases and use them to denigrate the service that is made available to 840,000 patients a year.

Professor Norman Browse, the president of the Royal College of Surgeons said: I know what I would choose for me or my family faced with the choice between a short trip to a hospital with incomplete support facilities or five minutes longer in an ambulance to a fully equipped casualty department, backed up by the right specialist teams. At present, we are diluting our limited expertise. The proposed changes should put that right. The Lewisham community health council said: We accept the closure of the accident and emergency department on the Guy's site provided that acceptable and appropriate alternative services are developed and working satisfactorily on the Lewisham and King's site.

Ms Primarolo

Where are the replacement facilities for the accident and emergency units that have already closed?

Dr. Mawhinney

I have already given the hon. Lady and the House an assurance on that.

It has been interesting that tonight's debate has been virtually all about hospitals. We have heard virtually nothing about general practitioners and primary care.

I will give the House a few examples of what the Government are doing around London to address what is generally recognised to be the need to improve primary care. At the Chingford health centre, work will finish in August this year on improvements to the general practitioner consulting rooms, the reception area and the practice manager's accommodation. In addition, the centre will be made accessible for disabled patients.

As part of the Peterhouse project in Walthamstow, work will start in early 1995 on the development of a GP practice in conjunction with a church community building. Accommodation will be provided for visiting specialists and community staff. A substantial site has been purchased for the Forest road project in Walthamstow, with a view to developing premises for four GPs.

Under the Carisbrooke road project, the intention is to purchase a site this year to enable the development of a purpose-built medical complex, which will accommodate five GPs. In Leyton and Leytonstone, work will start in 1995 to build a primary care unit on the remaining wing of the Langthorn health centre in order to accommodate GPs and other primary services.

I shall deal now with the hospital-at-home scheme. It has the advantage of not only enabling patients who would otherwise go into hospital to remain at home but enabling patients who are in hospital to return home early. In Wandsworth, an intensive patient support at home scheme which deals with orthopaedic cases is due to become operational later this year. It will handle 300 patients in a full year, reducing their average length of stay in hospital from 22 days to 11 days.

In Kensington, Chelsea and Westminster, an orthopaedic and paediatric hospital at home service expects to prevent 78 hospital admissions and enable 177 early discharges from hospital. The Parkside hospital-at-home scheme expects to prevent 48 hospital admissions and enable 144 early discharges. In the Brent and Harrow area, the hospital-at-home scheme enables the early discharge of patients who have had hip replacement operations.

In Camden and Islington, the home choice scheme operated by the community trust has a capacity to provide health and social services care for up to 24 patients. The scheme providing post-hospital and intensive care for children at home expects to treat 100 patients this year. The Ealing hospital-at-home scheme is expected to prevent 20 hospital admissions and enable 180 early discharges. The Hounslow hospital-at-home scheme will enable 250 early discharges. I could go on and on, as we reconfigure primary health services.

We have had a look at the caring face of the Labour party when it comes to health. The care of the right hon. and learned Member for Monklands, East (Mr. Smith) stretches just as far as the television camera flex. We have had the opportunity to listen to the hon. Member for Holborn and St. Pancras. Judy Bennett will be disappointed tonight. In his election address, she wrote: Frank Dobson really knows what he's on about when it comes to the NHS". He could have fooled us.

We know what the hon. Gentleman thinks about Londoners. He thinks "we have failed those people, we have a lot to answer for. If we are honest we have a lot more to answer for in London than they have in some other parts of the country." We know what he thinks about business men. He thinks that they are stinking, lousy, thieving, incompetent scum. But we have no idea what he thinks about the health service. He got his facts wrong, he did not mention patients and there was no recognition of GPs.

Then there was the hon. Member for Sheffield, Brightside (Mr. Blunkett). They seek him here, they seek him there—he must be there because he is not here. The hon. Member for Dunfermline, East (Mr. Brown) told him that he could not speak and the right hon. and learned Member for Monklands, East told him not even to bother to come.

There we have them: the right hon. and learned Member for Monklands, East, the hon. Member for Holborn and St. Pancras and the hon. Member for Brightside—the Foggy, Compo and Clegg of the Labour health team. We have heard today the last of the summer whine. I am not so unchivalrous as to identify the hon. Member for Bristol, South with Nora Batty. They are interested in beds; we are interested in patients. More patients are being treated in fewer beds—that is what separates us. Londoners want patients to be treated and that is what they are getting, to a quality unmatched as never before. That is what we offer them next week.

Question put, That the original words stand part of the Question:—

The House divided: Ayes 201, Noes 279.

Division No. 227]	[10.00 pm
AYES
Adams, Mrs Irene	Burden, Richard
Ainger, Nick	Byers, Stephen
Ainsworth, Robert (Cov'try NE)	Caborn, Richard
Allen, Graham	Callaghan, Jim
Anderson, Ms Janet (Ros'dale)	Campbell, Ronnie (Blyth V)
Armstrong, Hilary	Campbell-Savours, D. N.
Ashton, Joe	Canavan, Dennis
Austin-Walker, John	Cann, Jamie
Banks, Tony (Newham NW)	Carlile, Alexander (Montgomry)
Barnes, Harry	Chisholm, Malcolm
Battle, John	Clapham, Michael
Beckett, Rt Hon Margaret	Clarke, Eric (Midlothian)
Bell, Stuart	Coffey, Ann
Benn, Rt Hon Tony	Cohen, Harry
Bennett, Andrew F.	Connarty, Michael
Benton, Joe	Cook, Frank (Stockton N)
Bermingham, Gerald	Cook, Robin (Livingston)
Berry, Roger	Corbett, Robin
Boyes, Roland	Corbyn, Jeremy
Bray, Dr Jeremy	Corston, Ms Jean
Brown, Gordon (Dunfermline E)	Cousins, Jim
Brown, N. (N'c'tle upon Tyne E)	Cox, Tom

Cunliffe, Lawrence	Marek, Dr John
Cunningham, Jim (Covy SE)	Marshall, David (Shettleston)
Dalyell, Tam	Marshall, Jim (Leicester, S)
Darling, Alistair	Martin, Michael J. (Springbum)
Davis, Terry (B'ham, H'dge H'l)	Martlew, Eric
Denham, John	Meacher, Michael
Dewar, Donald	Michael, Alun
Dixon, Don	Milburn, Alan
Dobson, Frank	Miller, Andrew
Dowd, Jim	Moonie, Dr Lewis
Dunnachie, Jimmy	Morley, Elliot
Dunwoody, Mrs Gwyneth	Morris, Rt Hon A. (Wy'nshawe)
Eastham, Ken	Morris, Rt Hon J. (Aberavon)
Enright, Derek	Mowlam, Marjorie
Etherington, Bill	Mudie, George
Field, Frank (Birkenhead)	Mullin, Chris
Fisher, Mark	Murphy, Paul
Flynn, Paul	Oakes, Rt Hon Gordon
Foster, Rt Hon Derek	O'Brien, Michael (N W'kshire)
Foulkes, George	O'Brien, William (Normanton)
Fraser, John	Orme, Rt Hon Stanley
Fyfe, Maria	Paisley, Rev Ian
Garrett, John	Parry, Robert
George, Bruce	Patchett, Terry
Gerrard, Neil	Pendry, Tom
Gilbert, Rt Hon Dr John	Pickthall, Colin
Godsiff, Roger	Pike, Peter L.
Golding, Mrs Llin	Pope, Greg
Gordon, Mildred	Powell, Ray (Ogmore)
Graham, Thomas	Prentice, Ms Bridget (Lew'm E)
Grant, Bernie (Tottenham)	Prentice, Gordon (Pendle)
Griffiths, Nigel (Edinburgh S)	Primarolo, Dawn
Griffiths, Win (Bridgend)	Purchase, Ken
Grocott, Bruce	Quin, Ms Joyce
Gunnell, John	Radice, Giles
Hanson, David	Randall, Stuart
Henderson, Doug	Raynsford, Nick
Hinchliffe, David	Redmond, Martin
Hoey, Kate	Reid, Dr John
Hogg, Norman (Cumbernauld)	Rendel, David
Home Robertson, John	Robertson, George (Hamilton)
Hood, Jimmy	Robinson, Geoffrey (Co'try NW)
Hoon, Geoffrey	Roche, Mrs. Barbara
Howarth, George (Knowsley N)	Rogers, Allan
Howells, Dr. Kim (Pontypridd)	Ross, Ernie (Dundee W)
Hoyle, Doug	Rowlands, Ted
Hughes, Roy (Newport E)	Ruddock, Joan
Hughes, Simon (Southwark)	Sheerman, Barry
Illsley, Eric	Sheldon, Rt Hon Robert
Jackson, Glenda (H'stead)	Shore, Rt Hon Peter
Jamieson, David	Short, Clare
Johnston, Sir Russell	Simpson, Alan
Jones, Barry (Alyn and D'side)	Skinner, Dennis
Jones, Lynne (B'ham S O)	Smith, Andrew (Oxford E)
Jones, Martyn (Clwyd, SW)	Smith, C. (Isl'ton S & F'sbury)
Keen, Alan	Smith, Rt Hon John (M'kl'ds E)
Kennedy, Jane (Lpool Brdgn)	Smith, Llew (Blaenau Gwent)
Kilfoyle, Peter	Soley, Clive
Lestor, Joan (Eccles)	Spearing, Nigel
Lewis, Terry	Squire, Rachel (Dunfermline W)
Litherland, Robert	Stevenson, George
Livingstone, Ken	Stott, Roger
Lloyd, Tony (Stretford)	Strang, Dr. Gavin
Llwyd, Elfyn	Straw, Jack
Loyden, Eddie	Taylor, Mrs Ann (Dewsbury)
Lynne, Ms Liz	Taylor, Matthew (Truro)
McAllion, John	Thompson, Jack (Wansbeck)
McCartney, Ian	Vaz, Keith
McKelvey, William	Wardell, Gareth (Gower)
Mackinlay, Andrew	Wareing, Robert N
McLeish, Henry	Wicks, Malcolm
McMaster, Gordon	Williams, Rt Hon Alan (Sw'n W)
McNamara, Kevin	Williams, Alan W (Carmarthen)
McWilliam, John	Wilson, Brian
Madden, Max	Winnick, David
Mahon, Alice	Wise, Audrey
Mandelson, Peter	Worthington, Tony

Wray, Jimmy	Tellers for the Ayes:
Wright, Dr Tony	Mr. John Spellar and
Young, David (Bolton SE)	Mr. John Cummings.
NOES
Ainsworth, Peter (East Surrey)	Emery, Rt Hon Sir Peter
Alexander, Richard	Evans, David (Welwyn Hatfield)
Alison, Rt Hon Michael (Selby)	Evans, Jonathan (Brecon)
Allason, Rupert (Torbay)	Evans, Nigel (Ribble Valley)
Amess, David	Evans, Roger (Monmouth)
Ancram, Michael	Evennett, David
Arbuthnot, James	Faber, David
Arnold, Jacques (Gravesham)	Fabricant, Michael
Arnold, Sir Thomas (Hazel Grv)	Fenner, Dame Peggy
Ashby, David	Field, Barry (Isle of Wight)
Aspinwall, Jack	Fishburn, Dudley
Atkinson, David (Bour'mouth E)	Forman, Nigel
Atkinson, Peter (Hexham)	Forsyth, Michael (Stirling)
Baker, Nicholas (Dorset North)	Forth, Eric
Baldry, Tony	Fox, Dr Liam (Woodspring)
Banks, Matthew (Southport)	Fox, Sir Marcus (Shipley)
Banks, Robert (Harrogate)	Freeman, Rt Hon Roger
Batiste, Spencer	French, Douglas
Bellingham, Henry	Fry, Sir Peter
Bendall, Vivian	Gallie, Phil
Beresford, Sir Paul	Gardiner, Sir George
Biffen, Rt Hon John	Garel-Jones, Rt Hon Tristan
Blackburn, Dr John G.	Garnier, Edward
Body, Sir Richard	Gill, Christopher
Bonsor, Sir Nicholas	Gillan, Cheryl
Booth, Hartley	Goodlad, Rt Hon Alastair
Boswell, Tim	Goodson-Wickes, Dr Charles
Bottomley, Peter (Eltham)	Gorman, Mrs Teresa
Bottomley, Rt Hon Virginia	Gorst, John
Bowden, Andrew	Grant, Sir A. (Cambs SW)
Bowis, John	Greenway, Harry (Ealing N)
Boyson, Rt Hon Sir Rhodes	Greenway, John (Ryedale)
Brandreth, Gyles	Griffiths, Peter (Portsmouth, N)
Brazier, Julian	Grylls, Sir Michael
Bright, Graham	Hague, William
Brown, M. (Brigg & Cl'thorpes)	Hamilton, Rt Hon Sir Archie
Browning, Mrs. Angela	Hamilton, Neil (Tatton)
Bruce, Ian (S Dorset)	Hampson, Dr Keith
Budgen, Nicholas	Hannam, Sir John
Burns, Simon	Hargreaves, Andrew
Burt, Alistair	Harris, David
Butler, Peter	Haselhurst, Alan
Carlisle, John (Luton North)	Hawkins, Nick
Carrington, Matthew	Hawksley, Warren
Carttiss, Michael	Hayes, Jerry
Churchill, Mr	Heathcoat-Amory, David
Clappison, James	Hendry, Charles
Clark, Dr Michael (Rochford)	Higgins, Rt Hon Sir Terence L.
Clarke, Rt Hon Kenneth (Ruclif)	Hill, James (Southampton Test)
Clifton-Brown, Geoffrey	Hogg, Rt Hon Douglas (G'tham)
Coe, Sebastian	Horam, John
Congdon, David	Hordern, Rt Hon Sir Peter
Conway, Derek	Howard, Rt Hon Michael
Coombs, Anthony (Wyre For'st)	Howell, Rt Hon David (G'dford)
Coombs, Simon (Swindon)	Howell, Sir Ralph (N Norfolk)
Cope, Rt Hon Sir John	Hughes Robert G. (Harrow W)
Cormack, Patrick	Hunt, Rt Hon David (Wirral W)
Couchman, James	Hunt, Sir John (Ravensboume)
Cran, James	Hunter, Andrew
Curry, David (Skipton & Ripon)	Jack, Michael
Davies, Quentin (Stamford)	Jenkin, Bernard
Davis, David (Boothferry)	Jessel, Toby
Day, Stephen	Johnson Smith, Sir Geoffrey
Deva, Nirj Joseph	Jones, Gwilym (Cardiff N)
Devlin, Tim	Jones, Robert B. (W Hertfdshr)
Dickens, Geoffrey	Kellett-Bowman, Dame Elaine
Dorrell, Stephen	Key, Robert
Douglas-Hamilton, Lord James	Kilfedder, Sir James
Dover, Den	King, Rt Hon Tom
Duncan, Alan	Kirkhope, Timothy
Duncan-Smith, Iain	Knapman, Roger
Durant, Sir Anthony	Knight, Greg (Derby N)
Eggar, Tim	Knight, Dame Jill (Bir'm E'st'n)
Elletson, Harold	Knox, Sir David

Kynoch, George (Kincardine)	Sainsbury, Rt Hon Tim
Lang, Rt Hon Ian	Scott, Rt Hon Nicholas
Legg, Barry	Shaw, David (Dover)
Leigh, Edward	Shaw, Sir Giles (Pudsey)
Lennox-Boyd, Mark	Shepherd, Colin (Hereford)
Lester, Jim (Broxtowe)	Shepherd, Richard (Aldridge)
Lidington, David	Shersby, Michael
Lilley, Rt Hon Peter	Sims, Roger
Lloyd, Rt Hon Peter (Fareham)	Skeet, Sir Trevor
Lord, Michael	Smith, Sir Dudley (Warwick)
Luff, Peter	Smith, Tim (Beaconsfield)
Lyell, Rt Hon Sir Nicholas	Soames, Nicholas
MacGregor, Rt Hon John	Speed, Sir Keith
MacKay, Andrew	Spicer, Sir James (W Dorset)
Maclean, David	Spicer, Michael (S Worcs)
McLoughlin, Patrick	Spink, Dr Robert
McNair-Wilson, Sir Patrick	Spring, Richard
Madel, Sir David	Sproat, Iain
Maitland, Lady Olga	Squire, Robin (Hornchurch)
Major, Rt Hon John	Stanley, Rt Hon Sir John
Malone, Gerald	Stephen, Michael
Mans, Keith	Stern, Michael
Marland, Paul	Stewart, Allan
Marlow, Tony	Streeter, Gary
Marshall, John (Hendon S)	Sumberg, David
Marshall, Sir Michael (Arundel)	Sweeney, Walter
Martin, David (Portsmouth S)	Sykes, John
Mates, Michael	Tapsell, Sir Peter
Mawhinney, Rt Hon Dr Brian	Taylor, Ian (Esher)
Mayhew, Rt Hon Sir Patrick	Taylor, John M. (Solihull)
Merchant, Piers	Taylor, Sir Teddy (Southend, E)
Mills, Iain	Temple-Morris, Peter
Mitchell, Andrew (Gedling)	Thomason, Roy
Moate, Sir Roger	Thompson, Sir Donald (C'er V)
Monro, Sir Hector	Thompson, Patrick (Norwich N)
Montgomery, Sir Fergus	Thornton, Sir Malcolm
Moss, Malcolm	Townend, John (Bridlington)
Nelson, Anthony	Townsend, Cyril D. (Bexl'yh'th)
Neubert, Sir Michael	Tracey, Richard
Newton, Rt Hon Tony	Trend, Michael
Nicholls, Patrick	Trotter, Neville
Nicholson, David (Taunton)	Twinn, Dr Ian
Nicholson, Emma (Devon West)	Vaughan, Sir Gerard
Norris, Steve	Viggers, Peter
Onslow, Rt Hon Sir Cranley	Waldegrave, Rt Hon William
Oppenheim, Phillip	Walden, George
Ottaway, Richard	Walker, Bill (N Tayside)
Page, Richard	Waller, Gary
Paice, James	Wardle, Charles (Bexhill)
Patnick, Irvine	Waterson, Nigel
Patten, Rt Hon John	Watts, John
Pawsey, James	Wells, Bowen
Peacock, Mrs Elizabeth	Wheeler, Rt Hon Sir John
Porter, Barry (Wirral S)	Whitney, Ray
Portillo, Rt Hon Michael	Whittingdale, John
Rathbone, Tim	Widdecombe, Ann
Redwood, Rt Hon John	Wiggin, Sir Jerry
Renton, Rt Hon Tim	Wilkinson, John
Richards, Rod	Willetts, David
Rifkind, Rt Hon. Malcolm	Winterton, Mrs Ann (Congleton)
Robathan, Andrew	Wolfson, Mark
Roberts, Rt Hon Sir Wyn	Wood, Timothy
Robertson, Raymond (Ab'd'n S)	Yeo, Tim
Roe, Mrs Marion (Broxboume)
Rowe, Andrew (Mid Kent)	Tellers for the Noes:
Rumbold, Rt Hon Dame Angela	Mr. Sydney Chapman and
Ryder, Rt Hon Richard	Mr. David Lightbown.
Sackville, Tom

Question accordingly negatived.

Question, That the proposed words be there added, put forthwith pursuant to Standing Order No. 30 (Questions on amendments) and agreed to.

MADAM SPEAKER forthwith declared the main Question, as amended, to be agreed to.

Resolved, That this House noting the rapid advance of medical science, population migration from Inner London and the increase in provision of specialist services outside the Capital, believes that the National Health Service must respond to these changes; congratulates the first government in 100 years prepared to tackle these issues; believes that the Government's long-term programme of strategic change is already leading to better services for patients, especially better primary care, and will strengthen centres of excellence in teaching and research and lead to a more sensible use of resources; and condemns her Majesty's Opposition for cynically treating the National Health Service in London as a party political battleground regardless of the interests of either staff or patients.