National Health Service (London)

HC Deb 21 October 1994 vol 248 cc527-98 9.34 am

Mr. Harry Cohen (Leyton)

I beg to move, That this House expresses its anxiety at the current state, and future prospects, of the National Health Service in London; considers that claims made by Health Ministers that there are too many hospital beds in the capital and an over-allocation of health resources, are not proven; notes that many of London's health authorities and trusts face chronic levels of debt due to Government underfunding of the National Health Service, and this along with the 'internal market' is having a devastating impact on London's health service; notes that accident and emergency units work under increasing crisis conditions; notes that the London Ambulance Service has been reduced to the worst ambulance service in the country; notes that general practitioners in many parts of London receive less than the national average to treat their patients and that they face an increasing workload due to the impact of hospital closures; considers that Outer London's health service is also suffering from the Government's health policies resulting in large debts, large waiting lists and repeated cuts in treatment provision; notes that there are 100,000 on waiting lists for treatment in the capital but that the number of people affected is much higher; and so calls upon the Government to heed the voice of the vast majority of Londoners, and to introduce an immediate moratorium on further bed reductions and hospital closures in the capital, whilst work is urgently undertaken to shift the system toward the health care Londoners need.

I am pleased to have won this debate. I have chosen the subject of the national health service in London because it is of great importance to most Londoners. There is considerable concern over its current state and its prospects, if being run down can be called a prospect. For many people, it is a life-and-death issue.

First, I pay tribute to nurses, doctors and other health workers who provide magnificent care, increasingly against the odds and against current trends. I pay tribute to those doctors, nurses and health workers in my local hospital, Whipps Cross, especially those in ward B3, who, for the past four weeks, have been providing excellent care for my mother.

As I said, health workers, in their important caring role, are having to endure increasingly arduous, testing and demoralising conditions. Many of them are exploited and underpaid. Many of the auxiliary nurses and care assistants, for example, work very long hours–13-hour days are not uncommon. One nurse told me that her job description was to assist, but, actually, she and the other nurses ended up doing the full nursing job.

In many ways, it is a cheap labour force in our hospitals, yet the Government are resisting the nurses' pay claim. Ministers have said that they will not allow any claims beyond 2 per cent. That is from a Government who themselves have been tainted with greed and sleaze, and who have allowed the NHS managerial salaries bill to rise by 211 per cent. in the three years between 1989–1990 and 1992–93, while £95 million was spent on redundancy payments for, among others, nurses. Nurses do a tremendous job under increasing pressures, and they should get a pay rise that reflects their productivity and worth.

I could fill a speech such as this about the health service with many examples of individual cases, but I shall cite only a few current cases from my mailbag. There was the case of a man who was discharged from hospital far too early—in this instance, following a vasectomy. He awoke at 11.30 am and was discharged at 12.40. On being discharged, he collapsed and bled internally. His genitals turned black and distended and he was unable to return to work for weeks.

There was the case of one of my constituents who had a tonsillectomy after waiting for two years. He then got a wound infection and a re-growth of the disease tissue and had to begin the whole process of waiting again—three months' wait just to get an out-patient appointment, and he still has a long wait for a second operation. He tells me that he has been suffering pain and side effects for three and a half years.

Then there is the case of the young man with a lump and pain in his groin, who was told that it would take two years to receive an operation on the national health service. He struggled and took out a £1,800 loan for a private operation. It was a good job he did so, because a ruptured hernia was discovered. There was the case of the man in the accident and emergency unit with severe chest pains, who spent eight hours on a trolley waiting for a bed. A pensioner whom I saw last month at Leytonstone station told me that her appointment to see a consultant was for August 1995. All that time, of course, she is not counted as being on the official waiting list.

As I said, citing such cases could take up the entire debate, but I want to move on to the issues and the arguments. It is worth remembering, however, that many thousands of individuals are behind those issues and arguments, and that they are affected by the cuts in our health service.

First, I want to concentrate on the proof that London is not over-bedded. Reports have claimed that London is over-bedded, and Health Ministers have leaned on that claim very heavily for the implementation of their policies. I believe that some, like the Tomlinson report, were set up by the Government deliberately to reach that conclusion.

Tomlinson estimated that between 2,000 and 7,000 beds could become "surplus" before the end of the decade. The Government's document "Making London Better", which was published in February 1993, refers to a rationalisation of acute hospital services involving a reduction in requirement for hospital beds of 15 to 20 per cent.–2,000 to 2,500 beds—over the next four or five years.

Thousands of bed cuts have already taken place, and many more are in the pipeline as a result of the assumption that London is over-bedded. London lost 28 per cent. of its hospital beds between 1986 and 1991. The assumption has been increasingly challenged and discredited. It is challenged on anecdotal evidence that people face long delays before a bed becomes available and that patients have to wait on trolleys. That may be anecdotal, but it is real for many people. Perhaps the Government can explain that contradiction. If that is not caused by a shortage of beds, presumably the cause is the system of management.

Waiting lists continue to rise. That does not imply surplus beds. Perhaps the Government can explain that contradiction. We must also consider cancelled operations. North East Thames regional health authority recently said: Between April and June of this year, hospitals across the region recorded 2,408 patients who had their operations were cancelled; 558 of whom were not readmitted within a month. If there are surplus beds, why are there such levels of cancellations? The Government should explain that.

In its 1992 working paper entitled "Acute Health Services in London", the King's Fund started the more recent academic challenge to the assumption that London is over-bedded. It divided London into three categories: high status, urban and inner deprived. It stated that there were more beds in the deprived sector than the average. However, that was also the case in similar areas such as central Birmingham and Liverpool. That is historic, but the higher than average bed provision matches the pattern of poor health status. Therefore, the higher level of beds corresponds to the higher level of need.

Professor Jarman, a respected academic in the field, has joined the attack on Tomlinson. He said that Tomlinson failed to include geriatric and non-acute beds, and that, when the results are standardised for age, there is only a 0.2 per cent. difference. Professor Jarman continued: Hospital use in London is comparable to national norms, contrary to the claim that Londoners use more hospital services than they should. Professor Jarman extrapolates that both acute beds and all beds per resident in London are now at the national average.

Mr. Iain Duncan Smith (Chingford)

I congratulate my neighbour, the hon. Member for Leyton (Mr. Cohen), on securing the debate and on being first on the list. That is something I have yet to achieve.

However, I want to question the supposed differences in the Tomlinson and Jarman figures, because there has been some dispute about them. It is clear that Tomlinson had a much tighter focus than Jarman. He considered acute beds specifically, and that led to the original report. However, Jarman widened the issue to all beds in London. There has never been an argument that there are not enough beds in London in all areas. However, the question is, are there too many acute beds and not enough in other areas of necessary treatment? That is where the argument lies.

Mr. Cohen

I believe that Tomlinson has been increasingly discredited. The Government claim that there were too many beds in London overall. That is why the number of beds is being reduced and hospitals are being closed right across London.

Professor Jarman is supported by the King's Fund in its report entitled "London: The Key Facts" which was published in April 1994. The report states that there are the same number of beds in inner London as in other conurbations.

As well as the centres of excellence which are renowned worldwide, London has special health needs. It has higher than average numbers of elderly and housebound people, HIV and AIDS patients, alcoholics, substance abusers, people with severe mental health problems, homeless people, single homeless and refugees. In addition, there are the tourists and commuters, who do not always show up in the official figures.

Professor Jarman has said: Bed closures should take account of London's relatively poorer health and primary care circumstances, longer hospital waiting lists, poorer provision of residential homes and evidence from the Emergency Beds Service of increasing pressure on beds. In its August report "What's Next for London's Health Care?" the King's Fund called for no more acute reductions overall and great care about A&E Departments, while the pressure on both remain as intense as they are now.

Mr. David Congdon (Croydon, North-East)

Does the hon. Gentleman agree that it would have been more helpful if the King's Fund had carried out more original research, rather than simply relying on the research of Professor Brian Jarman? The earlier report in 1992 was excellent, and Tomlinson drew on it. Unfortunately, the latest report is nothing more than a rehash of Jarman's discredited work.

Mr. Cohen

The Conservatives were happy to quote the King's Fund when it led them to close hospitals and beds. However, now that the King's Fund is saying that there should be no more acute closures, it is being renounced by the Conservatives. That argument simply will not do.

London has fewer acute beds per head of population than Newcastle, Greater Manchester, Liverpool, Sheffield and Leeds. The United Kingdom has fewer acute beds per head of population than Germany, France, Belgium, the Netherlands, Ireland and Spain. Paris and Rome have 50 per cent. more beds per head of population than London, and Berlin has twice as many. However, the Government are absolutely obsessed by their false assumption that there are too many beds. As a result, 16 hospitals face a serious risk of closure. They include Guy's, Bart's, the Queen Elizabeth in Hackney, Oldchurch and many others.

There are no longer continuing care beds for the elderly in areas such as Bromley. There are just six in Kingston, and virtually no provision in Greenwich, Harrow, Hounslow and many other parts of London. The choice for many of those elderly Londoners is to struggle alone at home or be forced into private nursing homes, some of which are unmonitored and might well be dangerous. What a way to treat the generation which won the war for this country.

It is not just a question of over-bedding. I want now to consider the allocation of health resources.

Mr. Bernard Jenkin (Colchester, North)

I note the hon. Gentleman's admiration for the Italian health service in Rome. I hope that he will not take us in that direction. I speak for an Essex constituency. The hon. Gentleman has compared the number of beds per head of population, but Essex also has big social problems, such as a heavy preponderance of elderly people. We are miles behind because of the London effect, which displaces resources to the centre away from the surrounding home counties. What is the hon. Gentleman's solution to that?

Mr. Cohen

That is not true. I do not really want to jump ahead of my speech, but I will do so now, to inform the hon. Gentleman that waiting lists in Essex have increased by 30 per cent. under this Government. That gives the lie to the hon. Gentleman's argument.

The Government have the false assumption that there are too many beds in London. As I have explained, that simply is not true, and the Government should reverse their attitude in that respect. There is also not an over-allocation of health resources to London.

London has 15 per cent. of the English population, but its share of NHS hospital spending is a fraction over 15 per cent. this year. However, within that is the provision for special needs to which I have referred, London weighting and the higher cost of the teaching hospitals. London is not overfunded. The King's Fund Research Institute, which Conservative Members do not like now that it is producing this kind of information, has said: instead of losing £17 million, London should gain an extra £200 million.

Mr. James Clappison (Hertsmere)

The hon. Gentleman referred to underfunding in London. I would be interested to know whether he is arguing that resources should be transferred from other regions, or for an increase in health service expenditure. If that is the case, would he share my interest in hearing the Opposition Front-Bench spokesman's response to what he has just said?

Mr. Cohen

The hon. Member for Hertsmere (Mr. Clappison) is jumping ahead of my speech. There should be increased resources for the national health service in London and throughout the country. One thing that can be done first is stop the chronic wastage in spending. I have some examples. The King's Fund, in "London: The Key Facts", states: newly emerging evidence suggests that these weighted capitation targets underestimate the needs of inner city areas. The Department of Health itself commissioned a York university report, which it received in April, but, in its jargon, it is still being evaluated. The Government are sitting on that report. It is deliberate procrastination. I understand that the report states that, taking account of social deprivation, money would come to many areas of London. It is a scandal that the Government are sitting on those facts while they push ahead with financial cuts and closures.

Mr. Nigel Spearing (Newham, South)

I am sure that my hon. Friend joins me in deploring the Secretary of State's absence, in view of her part in London hospital closures. Does my hon. Friend agree that allocations to health services are important in regard to the new trusts? I am sure that my hon. Friend is aware that, in east London, there are applications for trusts on a borough basis for community health services. There is a very good case for them, and they are being applied for, but the Secretary of State has not yet decided. There must be an overriding reason for such trusts as against a three-borough trust, which would tend to be more bureaucratic.

Mr. Cohen

My hon. Friend makes a good point. Borough trusts are wanted in his area of Newham. Of course, the financial squeeze is leading to trusts merging in ever larger conglomerations.

Under the weighted capitation formula, it has been estimated that £119 million will be siphoned off from London's annual health spending by the end of the century. Outer London is the worst affected. It will lose £96 million out of £119 million. Many boroughs are big losers under the capitation formula.

The internal market is having an appalling effect. In 1992, the King's Fund forecast that 15 major acute hospitals and postgraduate specialist hospitals would close before the year 2000 because of the internal market. That is an underestimate. There is very little effective planning and no stability for London's health services because those values conflict with the internal market, and the internal market takes precedence every time.

Purchasers and providers, as well as increasing bureaucracy in the NHS, are driven by their own monetary considerations rather than by the treatment that patients need. Nurses and other essential health workers have been squeezed out while managers and accountants have proliferated.

There is precious little co-ordination of overall health services. For example, I have written to the Minister and the regional health authority about children's beds in London. Trusts are announcing closures without concern for implications elsewhere.

In July last year, a well-established right-wing medical figure, Dr. James Le Fanu, wrote an article in The Daily Telegraph referring to the anarchy of a free market in health which is based on ideas of 'what ought to work', rather than what actually does work. The anarchy of the internal market in health is having a devastating and destructive impact in London.

Similarly, with the internal market, trust and health authority debt, which is caused by Government underfunding, is driving down London's health service. My own health authority, Redbridge and Waltham Forest, has a deficit for the current year of £7.2 million. Its recently published purchasing intentions show that the deficit for 1995-96 could be £9 million on top of the £7.2 million. That has serious implications, which could lead to trust mergers.

Following trust mergers always comes so-called rationalisation, with much health care being scrapped. Perhaps even the newly built King George hospital, which is already running at under-capacity despite local waiting lists because of its own debt problems, could be closed, or—horror of horrors—even Whipps Cross hospital in my area could be on a future agenda if the debt keeps recurring. I promise Ministers that, if Whipps Cross is threatened with closure, there will be a bitter battle which will make the recent M11 protest in my constituency seem like a tea party.

It is not just district health authority debt. My local community health council says: Forest health care trust will lose £1 million yet it is expected to increase activity by 7.5 per cent. We are very aware of the increasing pressure on Whipps Cross hospital and other FHT services due to previous rounds of 'efficiency savings'. We consider that these have already led to a decline in the quality of service and would vehemently reject the suggestion that more cuts can be made without seriously damaging services.

Debt drives costs right across London. Brent and Harrow has budget cuts of between £5 million and £15 million. Camden and Islington faces a possible £27 million cut in its annual budget. Merton, Sutton and Wandsworth faces an estimated £17 million budget cut. The debt problem is chronic, but it is the Government's tool to run down our health service and close hospitals.

Since 1990, a fifth of the capital's accident and emergency units have closed–12 in the past four years. There have been closures in surrounding areas also. That has increased the burden on existing A and E units, including at Whipps Cross in my constituency. A dozen more could close. Harold Wood hospital in Havering has already been closed, they say to be refurbished, but when it is reopened, the busier A and E at Romford's Oldchurch will close.

Bart's is due to close in January, despite massive objection. There are plans to take in Central Middlesex, Edgware, Mount Vernon, Hammersmith, Ealing or West Middlesex, Queen Mary's at Roehampton, Chase Farm or North Middlesex, Queen Elizabeth at Hackney, Whittington or the Royal Free, and Guy's. Between them, those units handle 500,000 casualties per annum.

Mr. Duncan Smith

I know that the hon. Gentleman would not wish the record to be incorrect, and that he will come to this matter. Whipps Cross, which is in the hon. Gentleman's constituency and which serves my constituency, has a spending programme of between £23 million and £27 million, which includes improvements to A and E and new theatres, new treatments and specialisms. I am sure that the hon. Gentleman will want to make that point absolutely clear.

Mr. Cohen

The hon. Gentleman is jumping ahead of my speech. Spending money on hospitals does not stop the Government closing them down later.

There has been no specialty review of casualty services, and no London-wide plan. Piecemeal cuts and closures which are proposed by a dozen health authorities and trusts could decimate London's already depleted casualty services. A and E units need to be in close proximity to the populations they serve. If people have to travel further for emergency treatment—units that are open are more heavily burdened—lives will be lost. The Government should halt all further A and E closures in London, including the closure of Bart's.

I shall say a word about Casualty Watch. I saw its press release earlier this year, entitled Londoners left lying on trolleys in capital's casualty crisis. It mentioned that 58 patients had been lying on trolleys for more than three hours in 13 hospitals. One man had been on a trolley for 24 hours. A 92-year-old man had been on a trolley for seven hours. The press release quotes Ross Levinson of the Greater London Association of Community Health Councils as saying: If London's A and E departments cannot cope on a mild April day, they certainly could not cope if there was a disaster in London, or even on an ordinary winter's day. We need to stop A and E closures.

The London ambulance service, in its current form the creation of the Government, is probably the worst ambulance service in the country, and among the worst in Europe. The LAS achieves its target of attendance within eight minutes of an emergency call in only 11 per cent. of cases. It answers only 68 per cent. of 999 calls within the target time of 14 minutes. It has never recovered from the computer crash in November 1992. The chairman had to resign after an independent inquiry blamed management, talking about failures for trying to introduce an untried system against an impossible timetable.

I recall the Secretary of State blaming the workers at that time. Of course, the Government have done so again in the tragic case of 11-year-old Nasima Begum. The first call for the ambulance in her case was at 10.41 pm. The ambulance eventually arrived, after four calls, at 11.34 pm. She was in hospital at 11.38 pm. Fifty-seven minutes had elapsed, and the doctor said that they were 37 minutes too late to save her life. Only seven manned ambulances were available, instead of the 13 that should have been on standby that night, and in the confusion one available ambulance in Newham was overlooked.

Even worse than that, an LAS spokesman said: We are not in a position to say that this won't happen again". That is shocking. The Minister has promised more money for staff and ambulances. Let us hear of that in detail today.

Morale is a problem. Staff levels have been cut by 20 per cent. in the past decade. The Government should work with the trade union UNISON on the basis of its submission to the Health Select Committee of June this year to get the LAS back on its feet.

The Government place the emphasis on general practitioners, but they have done far too little in that area. They have given nowhere near the £250 million recommended by the King's Fund in 1992. The amount that they have given is a drop in the ocean when set against the impact of hospital closures. The Tomlinson report said that £140 million was needed just to bring all GP surgeries up to minimum standards. The way in which, and the extent to which, the Government are switching resources from hospitals to GP services received the thumbs down at the British Medical Association conference earlier this year.

The Guardian said that there were 1,000 substandard GP practices in the capital—some are even without hot running water, let alone a practice and there are probably tens of thousands of people the GPs fail to reach—including students, squatters, the homeless and those in temporary accommodation. A lot needs to be done to improve GP services, without the added burden imposed upon them by hospital closures.

The Government have spent some money, but its impact has been ineffectual. In its submission to this debate, the Royal College of Nursing said: The Government announced that it would invest £40 million in 1993/94 and an additional £85 million in 1994/95. However, there has been little tangible evidence of where money has been spent and what changes have been effected in London. Beyond the updating of some GP premises, evidence is lacking on the real improvements to primary care services.

The number of GPs per head of population is low. What are the Government doing to train and recruit more GPs? Not very much. The GP fundholder system creates a two-tier system that is unfair. Under that system, going for the "cheapest option" has a tendency to force out "clinical objectivity".

Far from tackling the serious problems that GPs face, the Government are just about to alienate GPs again with their performance-related pay proposal, which is irrelevant in London in the circumstances that I have described. Outer London has suffered under the Government. Both Tomlinson and Secretaries of State have said that outer London would benefit from inner-London reductions, but it has not. It has suffered huge debts, large waiting lists and repeated cuts in treatment provision. There is a real danger of hospital closures spreading out to outer London.

In my area, covering Redbridge and Waltham Forest, there is no surgery other than for emergency treatment, and urgent cases of people having babies and patients who have waited for more than 18 months. There is no elective surgery. People on the waiting list must wait 18 months, perhaps in pain and ańxiety, before they can receive treatment.

The crisis is spreading. It is not just in inner London; it is outside London as well. Essex's waiting lists grew by 30 per cent. in the 15 months to November 1993. Waiting lists grew by 20 per cent. in the home counties over that period, despite London's hospital closures. The Government NHS policies overall are to blame for the cuts throughout London and outside it.

Waiting lists are soaring; 100,000 is the official figure, but the number of people who are affected is much higher. Many people are on the pre-waiting lists, which I referred to earlier. My local GPs are calling for an independent inquiry into waiting times and rising waiting lists. In Waltham Forest and Redbridge, there was a 52 per cent. rise last year. Figures in the latest district health authority papers of 31 July show that 15,289 people are waiting for treatment.

That is the position across London. Waiting lists for the New River health authority area, covering Enfield and Haringey, were up 45 per cent. in the eight months to May 1994. In Barnet, they were up 8 per cent. in that period. Since Northwich Park hospital, located in Barnet, achieved trust status, waiting lists are up by 48 per cent. In Camden and Islington, waiting lists are up by 16 per cent. In East London and City, which has followed the Government's guidelines and has extra cash under capitation, 13,000 people are permanently on waiting lists. Of course, there is no wait for people going into private hospitals.

Mr. Oliver Heald (Hertfordshire, North)

The hon. Gentleman keeps talking about the number of people on waiting lists, but what about waiting times? They have fallen, have they not?

Mr. Cohen

The pre-waiting list time is still extremely high. The Government have fiddled the figures. In the past, we had clear figures because they were made up of deaths and discharges—people coming out of hospitals; now we have finished consultant episodes. A patient could be shuffled around between lots of consultants before he receives treatment and the Government can say that a lot more treatment is being carried out, but that is not the case.

The Government have wasted money on the internal market and on managers. For example, £140 million has been spent on the Philip Harris House hospital wing at Guy's. Since then, the Government have announced that Guy's is up for closure. At Chelsea and Westminster, there is a £200 million showpiece hospital. The beds there were left deliberately empty, despite high waiting lists.

In July this year, the Evening Standard talked of the Government being prepared to spend £200 million to speed up the closure of Bart's. The London Implementation Group, set up by the Government to enforce the changes and closures, has a £200 million annual budget, with a former Tory Member of Parliament as its chairman. All its meetings implementing the closures are held in secret. There are other issues that I have no time to go into.

Mr. Duncan Smith

Will the hon. Gentleman give way?

Mr. Cohen

No, because I want to finish my speech.

The nation's medical research and development is at risk. The Brentwood blood transfusion centre is to close. I have written to the Government about that. They say that a new computer system is to be installed. I hope that it is not another London ambulance service.

Through the crisis, the Government have ploughed ahead in a blind dogmatic way. The views of patients, doctors, nurses and Londoners have been ignored. Far from making London better, the Government's policies are leading to an extremely sick service for London. A large majority of Londoners are extremely worried about the rundown of their NHS and the Government should heed their voice and alter course. The chief executive of the King's Fund said: there should be no more acute bed reductions overall, and great care about A and E Departments.

At the very least, the Government should introduce a moratorium on all further bed reductions and hospital and casualty closures. There should be an independent inquiry into the position in London. The system should be moved away from its cuts and market mentality to one that provides proper health care, which Londoners need and deserve.

Several hon. Members

rose—

Mr. Deputy Speaker (Mr. Geoffrey Lofthouse)

Order. No fewer than 29 right hon. and hon. Members hope to take part in the debate. It is a tall order to get everyone in, but it would be helpful if hon. Members would bear it in mind that brief speeches would be of some assistance.

10.8 am

Mr. Peter Brooke (City of London and Westminster, South)

I must immediately express appreciation to the hon. Member for Leyton (Mr. Cohen) for having provided so uncontroversial a vehicle for me to work my passage back as a Back-Bench contributor. In the diarrhoea of language that is contained in his motion, there was no reference to an independent inquiry. For a moment, I had hoped that sanity had overtaken Opposition Members, but I notice that, in his closing paragraph, he said that, although such a reference had been omitted from the motion, he still wanted to have an inquiry. I shall come to that at the end of my speech.

Although I welcome the breadth of subject that the hon. Gentleman has afforded us in this debate, I hope that the House will forgive me if, after nearly 15 years of Trappism on constituency matters, my speech has a constituency bias, particularly in the direction of Bart's. However, I hope that I can frame it within the London-wide perspective.

I doubt that Kremlinologists will crawl over my speech for evidence of disenchantment with the Administration that I have just left, but if any such is detected, I hope that it will be correctly imputed to constituency concern rather than to any general bile, which I do not remotely feel. I am delighted that my hon. Friend the Minister of Health will respond to the debate, and I welcome him to the Dispatch Box.

I stress that I support the overall thrust of the policy which my right hon. Friend the Secretary of State announced in February 1993 under the title "Making London Better", which was substantially derived from the analysis of the Tomlinson report. I am not a blind admirer of that document, especially of its detail, but I support the central pillar and principle of my right hon. Friend's policy. I would do so even more enthusiastically in the light of evidence that the Government were prepared tactically to modify the application of the policy to reflect practical developments in the two years since Tomlinson reported.

Secondly, I am profoundly sympathetic to my right hon. Friend for the damnosa hereditas that she was bequeathed in London by decades of Ministers, although I accept that her immediate predecessor, my right hon. Friend the Minister of Agriculture, Fisheries and Food, had set his hand to the London plough. Perhaps I may illustrate my right hon. Friend's inheritance anecdotally.

In my first month in the House, I was invited, with characteristic enterprise, by a surgical team at Bart's to spend 24 hours with it as a proxy member of the team, so that I could understand the NHS from the inside. Towards the end of that day, when we knew each other better, we discussed the over-provision of specialties across what I think were at that time 14 teaching hospitals in Greater London.

That was in 1977, and the members of the surgical team were quite adamant about that over-provision, and equally adamant that we could not expect the profession to rationalise it, but that that would have to be done by a sensible alliance of administrators and politicians working in conjunction with the profession.

Ironically, 1977 was the year in which the London Health Planning Consortium was set up to examine just such subjects, and the House will recall the studies from 1978 to 1980 on radiotherapy, cardiology and cardio-thoracic surgery and the neuro-sciences. The kindest epitaph on the consortium's work is that the quality of the analysis was superior to the results that were achieved. Therefore, I genuinely sympathise with my right hon. Friend on the scale of the problem that she inherited, which, if anything, had been compounded by the previous inertia, whatever its motivation. That stricture applies to Governments of all colours.

I also start from a position of support for the NHS reforms. Like, I dare say, many London colleagues, I winced at that unlyrical acronym RAWP, but tolerated it because of the deficiencies outside London that it was intended to resolve. Perhaps we in London sometimes underestimate the scale of improvement outside London that it has secured.

In a similar vein, I think that the Department of Health sometimes looks at London through roseate spectacles. The briefing issued to Conservative Back Benchers for this debate, which presumably emanates ultimately from the Department of Health, is written in places as if Professor Jarman and the recent analysis by the King's Fund did not exist.

I was much less happy about the quality of the NHS trans-authority accounting. Authorities in London which were treating extra-London patients were generally doing so because more sophisticated operations were required, but were being compensated for them at average rather than actual cost, and often up to two years late. That meant that our constituents in London were effectively doubly subsidising the constituents of colleagues from outside London. In principle, the NHS reforms correct that unfairness, although I acknowledge that it is contingent upon the thoroughness of our accounting.

That was the background against which developments at Bart's have taken place. This remarkable hospital, derived from and still underpinned by an inspirational Christian tradition, responded to the challenge set for it by Tomlinson—and, in due course, by the Secretary of State—in a spirit of genuine collaboration. The impressive recent financial figures which Bart's has provided give the lie to the financial pessimism expressed by Tomlinson. I note that my neighbour, the hon. Member for Hackney, South and Shoreditch (Mr. Sedgemore), nods his assent. I hope that the Minister will acknowledge that, while recognising that the game has moved on. [Interruption.]

The game has moved on in the sense that Bart's has had discussions with its partners in the Royal Hospitals trust about the best way to merge their combined strengths, although historians may well wish to comment on whether cutting the umbilical cord between Bart's and the Homerton was in the best interests of patients in Hackney. Historians will no doubt also evaluate the comparative strengths of Bart's and its partners as they approach the merger.

Before I entered the House, I made my living from the interaction of human beings in organisations, and I would have predicted a greater chance of success, especially when so historic a site as Bart's is involved, if significant disengagement from the Bart's site had been accompanied by a proportionate generosity elsewhere towards those who were joining them from Bart's. I say that especially in the light of the talent that will be coming, and I express a general doubt as to whether that magnanimity has so far been greatly in evidence.

Critical both to the merger and to my right hon. Friend's place in NHS history is that it should be carried through successfully. That in turn depends upon excessive attention to morale rather than to a seemingly casual neglect of it. Leadership of an army in temporary retreat calls for skills and character of a high order. I mean no personal disparagement when I say that I doubt that leadership of that quality is currently being deployed. The test of history will be how many of the great strengths of Bart's will survive to infuse and enthuse the new body. The departure of clinicians, academics and leaders of teams of the highest quality will be a vivid and morbid verdict on the outcome. Of course buildings, traditions and ambiences contribute to the morale of organisations, but in the end human beings working together in a common endeavour are the true glory.

It was in that somewhat queasy atmosphere that the announcement in late July that the period of transition would he foreshortened from the previous estimates of between eight and 15 years to six years—I have seen five years quoted—struck such a further body blow. I hope that the Minister will devote an adequate amount of his speech to why this most deleterious abbreviation was suddenly imposed, and by whom. It is difficult to imagine a shock more calculated to depress morale at precisely the moment when morale needed to be built up.

Given the present public expenditure pressures and the huge backlog of repairs at the Royal London, which I have seen put at £37 million before the capital demands of enlargement are even tackled, foreshortening of the programme necessarily—or perhaps more correctly, unnecessarily—exacerbates apprehensions. Despite my right hon. Friend's uncharacteristic levity about the hospital's heritage, she belongs to a party which on the whole venerates institutions that have been 800 years in the making.

Mr. Duncan Smith

I am following my right hon. Friend's theme. In my area and in most others, there is tremendous sentiment about Bart's, which is considered to be a local hospital. Some of the decisions about the ending of some of its services and moves to the London work against the grain, and there is a feeling that the rationalisation might have been better at Bart's than at the London.

Mr. Brooke

I am grateful to my hon. Friend.

Those apprehensions are that a great hospital is being surrendered into a structure that will not even be the sum of the constituent parts, let alone something greater. The capital figures which I have heard quoted by the Department seem to allow nothing for the extra medical education costs.

I shall not dwell on the accident and emergency decision at Bart's, except to say that the heart of London has a concentration of employment which makes me regret that the City's willingness to make a private sector contribution towards a unique opportunity in a working population in my constituency which exceeds the national average by a factor of 17 was not encouraged.

Secondly, I hope that those notorious isochrones about which the hon. Member for Newham, South (Mr. Spearing) may well speak in the context of the ambulance service have again been tested since the City erected its ring of plastic, the difficulties of whose recent penetration are familiar to all those who travel to and from the City.

It was moving, earlier this week, to meet the most desperately wounded and injured of the Baltic Exchange victims and to know that he owed his life to Bart's being open. We cite Timothy Evans in capital punishment debates—nothing I know of Aesculapius suggests that he would have regarded a single life as immaterial.

I have said enough about this constituency matter, provided that my hon. Friend the Minister speaks about it at decent length in his reply. I am confident that he will reassure me. If he does not, I can only say that I have sat in this House long enough to remember the disruption of business achieved by my former parliamentary neighbour George Cunningham in support of St Mark's hospital in his constituency.

But those are the thoughts of a pessimist. I am an optimist, given what, at this juncture, a little imagination by the Department of Health can achieve. Fairness is a British characteristic that would serve my hon. Friend well as a watchword in these matters.

I said earlier that I would come back to the speech of the hon. Member for Leyton. On the wider issues and Labour's demands, I hope that my hon. Friend will resist the specious demand for another independent inquiry, which is a predictable recipe for paralysis—but that, acknowledging the maldistribution of beds in London at this time, both geographically and by character, and allowing for reallocations between categories, he will see virtue overall in halting the loss of beds in London until we are confident that we have reached equilibrium. It is difficult to provide a regional health service, let alone a national one, if there are not enough beds with which to do it.

For myself, I found persuasive the sober language of the King's Fund report during the recess on the subject of bed closures, although I can tell my hon. Friends that it does not unreservedly apply Professor Jarman's analysis. I look forward to hearing what my hon. Friend the Minister has to say about it.

10.21 am

Mr. Peter Shore (Bethnal Green and Stepney)

The right hon. Member for City of London and Westminster, South (Mr. Brooke) made an interesting speech. His concluding remarks, in which he called for a halt to the closures in London, were quite remarkable and not at all consistent with the line being taken by Ministers at the Department of Health. His remarks were supportive of my hon. Friend the Member for Leyton (Mr. Cohen), who has given us the opportunity to debate this important subject.

We are trying to be honest about what is happening. The original King Edward VII Trust report in 1992 and the Tomlinson inquiry, which was greatly influenced by the report, seemed to show that there was first, an excess of beds, and secondly, an excess of expenditure in London compared with the rest of the country. However, since then the statistics on which those conclusions were based have been eroded and undermined to the point where they lack any credibility.

I am not forgetting Professor Jarman, but the last two King Edward VII Trust reports are far from the original starting point in the whole miserable procedure of closing and rationalising London hospitals. Indeed, the last report says that London, far from having £80 million of excess resources that it should not have had, is £200 million short of what it should have were its needs to be properly assessed. It is no accident that the whole basis of allocation—weighted capitation money—throughout the country is now being re-examined. From what I hear, that is likely to produce very different results and an increased weighting in favour not just of London, but of inner-city areas generally.

What the Government forget about entirely is the whole underlying philosophy and thought behind an inner-city policy and the whole problem of inner cities, which is not just confined to London but occurs in many of our conurbations.

I do not want to speak at great length about the general problems of London; instead, I want to concentrate on the London ambulance service, which is a particular problem that affects 7 million Londoners. I have a special interest and concern because two of my constituents–11-year-old Nasima Begum and Abdul Barik, a pensioner, the first suffering from renal failure and the second from a heart attack—had to wait 53 minutes and 45 minutes respectively for an ambulance to reach them. I do not know whether they would have survived had the ambulances reached them sooner and transferred them to the Royal London hospital in Whitechapel. However, I do know that the waiting times for both of them were far too long and far above the guidelines published by the Government in their patients charter.

As the House knows, the charter requires that 50 per cent. of emergency calls should be answered within eight minutes and 95 per cent. within 14 minutes. It is a matter of regret that for the past five years only 63 per cent. of emergency calls—not 95 per cent.—have been answered within 14 minutes by the London ambulance service. The service has not just failed to improve: its performance has declined quite markedly from what it was as recently as the mid-1980s.

Many warnings have been given to Ministers during recent years, both from Labour's Front-Bench spokesmen and from many Back Benchers, including my hon. Friend the Member for Newham, South (Mr. Spearing), who has frequently raised the matter. There is little doubt that the LAS has been seriously underfunded during recent years. In our previous debate on 28 April, the Secretary of State acknowledged the shortfall by pledging an additional £14.8 million expenditure in the current year. Looking further ahead, she said that the number of paramedics now in place–400—would rise to 1,000 in 1996 and that the ambulance fleet would be enhanced and renewed. If those measures are thought to be necessary for 1996, it is a fairly obvious admission that the service is seriously underfunded and under-resourced now.

The 53-minute wait that poor Nasima Begum had to endure has moved the Secretary of State sufficiently for her to announce an inquiry. In her letter to Mr. William Wells, the chairman of the South Thames region, which was published on 10 October, the right hon. Lady asked him urgently to inquire into the particular facts behind the tragic death of young Nasima Begum and to report before Christmas.

I am much in favour of an inquiry, but it would be far better were it to be conducted not by the man who was at least formally responsible for the LAS, but by an outside independent person. I am not sure that it is a task that should have been entrusted to one person anyway. Nor do I like the strong steer that the terms of reference in the Secretary of State's letter has given to Mr. Wells. It says that he is to look at action needed to improve the deployment of LAS staff, rostering and the timing of annual leave, the incidence of absence for sickness and any other matters you consider to be relevant.

There are some other matters, one being the role of management. I do not think that even the most biased person would attribute the service's most disastrous experience, when its computer system blew up two years ago, to the ambulance men who staff the LAS.

Then there is the role of the Department of Health. It will be interesting to know how many representations were made to Ministers about the state of the vehicles employed by the London ambulance service, and the lack of paramedics, in the years before the Secretary of State's statement to the House on 28 April. Will Mr. Wells be inquiring into those matters, too? I put that question directly to the Minister, and hope that he can give some assurance concerning the scope and nature of the inquiry that I have described. I must tell him that, unless he can give some assurances, there will be considerable and justified scepticism about the findings of Mr. Wells's report.

Mr. Spearing

I wonder whether my right hon. Friend will allow me, before he sits down—

Mr. Deputy Speaker

Order. Has the right hon. Member for Bethnal Green and Stepney (Mr. Shore) given way?

Mr. Shore

I have just sat down.

10.29 am

Mr. Nicholas Scott (Chelsea)

This is not—although I must say that it slightly seems like it—a maiden speech. I look on it rather more, after 13 years, as breaking my duck in my second innings as a Back Bencher in this House. It has been an immense privilege to serve as a Minister for the past 13 years. Life in Government is demanding, but also very rewarding. It is, however, with some sense of relief that I return to the Back Benches and acquire an independence to speak—I hope on a range of issues—and can look forward to spending rather more time than I have over the past 13 years dealing with the interests of my constituents.

Those who leave office do not always do so without some feelings, perhaps, of not being quite so happy about what has happened to them. I certainly intend to give my unremitting support to the Prime Minister in the work that he has undertaken on behalf of this country. Like a former Minister of Health, Mr. lain Macleod, who happened also to be a great hero of mine in my early days in politics, I believe that the present Prime Minister understands profoundly what the British people want but also tries to persuade them to want something a bit better for the quality of their own lives and those of their families. He is to be much admired for that.

Like my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke), I shall spend a lot of my time on matters concerning my constituency, where we have three very important hospitals: the Chelsea and Westminster, the Royal Marsden and the Royal Brompton. Of course, those are all central London hospitals. I believe that, in central London, we are making much progress in the improvement of health care, at GP practitioner level—in family doctor and community health service provision—as well as in the hospitals themselves. It was a great experience for me recently to be able to open a new health centre in my constituency; it has five GPs and a range of community nurses and other nursing support, providing the highest quality of general practice health care to my constituents and others.

I acknowledge that there is a problem over the figuring, if I may put it that way, of health needs in central London. Of course, we all have the health care of our constituents to look after, but in calculating the level of health care that is necessary in central London, we cannot forget some of the extra pressures, which, inevitably, are put on those services. We all know that the policy of care in the community—admirable though it is in many respects to enable people to live in the community rather than in institutions—has put on the services of central London some very considerable extra pressures.

Although I understand from my hon. Friends that that policy has been altered and considerably tightened, the number of people being discharged from institutions for the mentally ill and the mentally handicapped has inevitably led to a considerable number of them ending up on the streets of central London. They inevitably place extra burdens on health provision in the capital itself, not just in terms of their regular needs, but as a result of the accidents that sometimes happen to them because of their lack of understanding and comprehension and their tendency to drift to alcohol and drug abuse. All have placed considerable extra burdens on the hospitals in central London.

In addition, central London has a large number of overseas visitors who from time to time will need extra health care. I believe that all those factors have perhaps not attracted the consideration that they deserve as we do the figuring for health needs in central London.

The Chelsea and Westminster hospital was and is an expensive hospital. It is, however, a marvellous hospital. I must have visited it 10 times since it was opened, and I believe that the enthusiasm and commitment of the staff and the quality of provision there will ensure it a glittering and important future. I must underline and emphasise the tremendous contribution made to it by those who came from the former Westminster hospital in terms of their commitment to their new hospital and in terms of the ethos and tremendous traditions that they have brought into the new institution. I commend all those who are playing their part in developing the contribution that they can make to health care, not just in my constituency, but in central London more generally.

I am particularly concerned about the pressures that exist at the moment in relation to the future of London's health services provision to relocate both the Royal Marsden and the Royal Brompton hospitals, which are an important part of my constituency. The latter, for personal reasons, has a particular place in my heart. Both became self-governing trusts in April this year. They have shown themselves capable of rising to the challenge of proving themselves to the internal market which we now have, and are seizing the opportunities provided to them to shape their own future and respond to patient choice.

Both of those hospitals are leading international centres of excellence. The Royal Marsden, in collaboration with its associated institute, the Institute of Cancer Research, plays a world-leading role in combating cancer, developing new anti-cancer drugs, surgical techniques and new approaches to radiotherapy treatments. The Royal Brompton, with its associated body, the National Heart and Lung Institute, is the United Kingdom's premier hospital for the research, diagnosis and management of heart and lung disease in adults and children. Its research in those fields positions it as a leader in Europe and further afield.

I very much hope that the region and the Department will look carefully and sympathetically at the plans that the Royal Brompton is now putting forward for the construction of a new clinic on its present site, to help it to continue its ground-breaking work in the fight against the nation's biggest killer, heart disease. I am convinced that the concept behind the clinic represents the next logical step for the hospital, and, of course, it is supported not just by those concerned directly with the hospital but by the major purchasers of its services. Rapid advances in new technology and treatments now mean that the clinic will not involve provision for additional in-patient beds—which may be of concern to some hon. Members—but they will meet patient choice increasingly with the provision of ambulatory care and day-case treatment.

The Royal Brompton, like other hospitals in London, has been the subject of intensive reviews by various agencies over the past few years. The 1993 cardiac specialty review recognised that the hospital should be the leading centre in west London. Its clinical research has a high reputation. The research assessment exercise by the Higher Education Funding Council for England, in December 1992, gave the Royal Brompton's sister organisation, the National Heart and Lung Institute, the highest possible rating for research of national and international calibre.

My right hon. Friend the Secretary of State for Health has characterised the 1990s as a decade in which to harness the energies of private enterprise to the good of our great public services, not least the national health service. That is an exciting and innovatory approach, and the public and private sectors are keen to support the Government in taking that step forward.

The Brompton clinic has the potential to be a first-class contributor to that concept. The intention is that it would be built at little or no additional cost to the taxpayer through the use of the private finance initiative. That would be a new departure for the NHS, but I emphasise that the clinic would be part of the health service. It would be one of the first health care projects of such a size to be funded using the private finance initiative. Private developers would provide the new clinic in return for the opportunity to develop certain other properties on the Royal Brompton site.

In the past, the private sector has sometimes been critical of NHS managers and officials for what is perceived to be their overly cautious approach to such joint ventures. Now, an innovative hospital trust has developed the basis for a sound partnership with the private sector. We cannot afford to see that falter because of old-style bureaucratic controls, which would be wholly contrary to the concept of the reforms that my right hon. Friend the Secretary of State introduced. Approval of the scheme, which has attracted considerable interest from the private sector, would send a clear signal from the Government that they are committed to expanding opportunities for partnership between the public and private sectors in the future national health service.

The Royal Brompton hospital trust is an international centre of leading-edge treatment for heart and lung disease for patients throughout the United Kingdom and Ireland. As I said, its research makes it a leader in Europe and wider afield, and its future should be considered in that international context. The Royal Brompton is not simply another west London hospital. Although it is located there, its services are essential for national and international use. I hope that when my hon. Friend the Minister, whom I welcome to his new responsibilities, examines the pattern of central London hospitals, he will feel able to support the Royal Brompton's plans for its clinic and to reject the rather grandiose alternative plans for health care provision in west London. The Royal Brompton has won its right to stay on merit and on merit alone.

I reiterate the point made by my right hon. Friend the Member for City of London and Westminster, South: the last thing that London's health care services need is yet another independent inquiry. That would be a recipe for further delay and uncertainty, whereas London's health service needs certainty and clarity about its future. My constituents are lucky to have outstanding health care, with the Chelsea and Westminster, Royal Brompton and Royal Marsden hospitals on their doorstep. I do not want the development of the future contribution that they can make to the quality of health care, far beyond the boundaries of my constituency, inhibited in any way by shortsightedness on the part of the region or Department of Health. I am sure that my hon. Friend the Minister, who takes a notably robust approach to bureaucratic meddling and delay, will employ those skills in the present circumstances.

10.43 am

Mrs. Barbara Roche (Hornsey and Wood Green)

Nye Bevan's book "In Place of Fear", published in 1952, included the statement: No society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means. By the time that Nye Bevan had written those words, he and the 1945 Labour Government had established the national health service to provide health care and the reassurance of health care to all. The present Government claim to have reformed the NHS to make it more efficient, so that it will provide a better service, but nothing could be further from the truth. They have produced a national health service that serves the bureaucrat, not the patient. This morning, I will describe the state of health care in my constituency and examine exactly who has benefited from the Government's reforms—who are the winners and who are the losers.

The post of chief executive of North Middlesex hospital, which serves my constituents, was recently filled by a contract with a management consultancy, Ernst and Young, under which one of its partners will perform that important role four days a week. For the services of that partner four days a week, Ernst and Young is paid in the region of £150,000 a year. Hon. Members in all parts of the House may like to ask themselves to whom that chief executive owes allegiance—to Ernst and Young or to the local people who use the hospital and rely on it for their health care?

Ernst and Young's entry in the 1994 directory of management consultants states that one of their main specialist activities is privatisation. How appropriate—and what a great basis on which to select a firm of private consultants to play a part in our national health service. I put those points to the Secretary of State for Health in a letter dated 29 September, to which I have yet to receive a reply. Perhaps the Minister will say whether he considers it appropriate for a health authority to pay a private firm for the services of one of its partners in the role of chief executive of a hospital trust. The public might think that the head of a hospital should be accountable to them as the local users of the service—and the losers in these so-called health reforms.

Mr. Hartley Booth (Finchley)

Does the hon. Lady agree that such consultants could improve the health service by introducing outside skills and experience?

Mrs. Roche

They are certainly making a great deal of money and adding a lot of bureaucracy. I would much rather see some of that £150,000 a year spent on patient care, on doctors, nurses and auxiliaries, than on unnecessary bureaucracy.

Ernst and Young is not the only management consultancy to benefit from the current local NHS climate. Price Waterhouse has just been paid £28,000 to conduct an investigation into whether one of the two accident and emergency departments covering Haringey and my neighbouring borough of Enfield should be closed. It is not necessary to spend £28,000, which could have been spent on patient care, to ascertain whether one of two well-used casualty departments should close, particularly when one of the health priorities in the local health strategy of the New River health authority is: Services should be local and accessible, as close as possible to people's home, family and friends. That is tremendous, but what will it mean in reality if one of the two accident and emergency units is closed?

When I wrote to the Secretary of State for Health about the matter, Baroness Cumberlege replied: clearly this study has to be paid for but this will be seen to have been well worthwhile if the review leads to improvement". What arrant nonsense that is—and what a complete waste of taxpayers' money, which could have been well used and well spent elsewhere. The noble Lady did not explain how closing an accident and emergency department could lead to an improvement. Perhaps the Minister will deal with that issue today. I recently received a letter from a very busy general practitioner group practice on the issue. It said: Any decision to close either casualty is gambling with human lives. We ask that you do all you can to prevent such an occurrence from taking place.

Who are the winners and who are the losers? Undoubtedly, some private hospitals and the private sector have been among the winners. One of my local health authorities has admitted that almost £500,000 of taxpayers' money was spent between April and August this year on providing private beds for mental health patients. Once again the winners are the private hospitals. The health authority also admitted that the figure will probably rise to £1 million by the end of this year and that the beds are at a considerable distance from St. Ann's, which is the hospital where mental health in-patients were treated before the health reforms. Apart from the cost to the taxpayer, it is wholly inappropriate to place patients in hospitals that have no links with the local community in which they will live when they are discharged. Once again, it is the patients who lose.

Other private firms also benefit. When the New River health authority—my local authority—issues press releases on its various initiatives, the contact number at the bottom of the release is not that of the health authority but a public relations firm in St. Albans. I wrote to the chief executive of that health authority asking him about its contract with the firm and how much taxpayers' money it costs. He replied to my letter, but for some unaccountable reason omitted to give me the figure. I wrote again asking him to remedy that omission, but to date he has not replied.

Once again it is the public, as taxpayers, who lose. What guidelines has the Minister's Department issued to health authorities about the amount of public money that they can spend on buying in public relations? My hon. Friend the Member for Sheffield, Brightside (Mr. Blunkett) recently established that management costs in the national health service have risen by 1,800 per cent. in five years and that this summer at least £37 million was spent by 143 trusts on logos and image building.

I was delighted to hear that the new Minister of State is renowned for his attacks on bureaucracy and his abhorrence of bureaucracy and waste. I trust that when he addresses the House today, he will respond to my arguments.

When I visited one of my local hospitals recently, I was interested to be introduced to its new director of marketing. I wonder how many other such directors there are in the country. It is obviously a growth industry—people moving from the private sector to the NHS to be directors of marketing. How much of that contributes to the battle against bureaucracy and waste and to the improvement of our national health service?

How absurd for the Secretary of State to say at her party conference last week: While I'm Secretary of State, bureaucracy will have no hiding place". Yet our national health service is the place where bureaucracy and waste flourish. Meanwhile, patients are suffering because the simple truth is that in our health service, under the uncontrollable monster of the internal market, the money is certainly not following the patients.

One of my constituents had been on a waiting list for a hip replacement operation at a central London hospital for three years. She came to my surgery, walking with sticks and in obvious pain and distress, to tell me that because the New River health authority did not have a contract with the central London hospital she had had to start again on a waiting list at another hospital. Fortunately, because of lengthy representations that I and others made, the health authority agreed to make an exception in her case. How many other patients who have not managed to contact their Members of Parliament—I am sure that many of my hon. Friends who speak later will give other examples—have been placed in such an appalling situation simply because the needs of patients did not fit in with the internal market system?

Let us take another example. Between 1990 and 1992, another constituent was treated at the Middlesex hospital for severe neck and shoulder pain. During her treatment her condition was carefully assessed and, thanks to the excellent consultant with whom my constituent built up a good and trusting relationship, the condition became manageable and she was able to stop attending the hospital. When things went wrong again this year, her GP wanted to refer her to the same consultant who had helped her last time, but found that he was no longer allowed to send patients to that department. In the words of my constituent: Instead of being seen in a clinic where I have built up a relationship with the doctor and which knows my history I must start all over again from the beginning at a new hospital. Some choice! … This would not be worth writing to you about if it was a lone case. Sadly I suspect that there are thousands like me who have lost their 'patient choice' with the NHS changes". That is some choice and some situation when the Secretary of State says that money follows the patient, but clearly it does not. That is the reality of the national health service in London today. In the words of a former member of the NHS executive, it is a "total shambles".

Today's national health service is like a national lottery. Ordinary people, patients, taxpayers and the long-suffering public know that they are the losers in the reforms and that the Government's friends—private firms, private hospitals and highly paid consultants—are the winners.

Mr. Duncan Smith

On a point of order, Mr. Deputy Speaker. I am aware that time is short and I will not detain you. My point of order arises from an answer during Agriculture questions yesterday. The matter is critical. There has been a report today that the Government are indicating that they may not pursue a court case against the Italians, which involves about £2.3 billion in fines. Yesterday, the Minister of Agriculture, Fisheries and Food said clearly in answer to a question on the subject that the Government had no such intention; yet today we hear that report. Have you heard from the Government that they intend to make a statement about a change in their policy on that matter?

Mr. Deputy Speaker

I have not been notified of any intended statement.

10.59 am

Dr. Ian Twinn (Edmonton)

I should first declare my interests in health care: I act as adviser to the Chartered Society of Physiotherapy and to the British Surgical Trades Association. Neither body has given me any advice about today's debate; I speak purely as an outer London Member of Parliament.

Conservative Members are grateful to the hon. Member for Leyton (Mr. Cohen) for raising this subject. As he can see, there is a wide range of interest in the health service in London.

I sometimes sit through these debates and listen to Opposition Members commenting on the same regions, hospitals and health service as us. They appear to see nothing but evil and harm in London's health service, whereas Conservative Members can see not only the problems, which we are tackling, but the great achievements. It would have been nice to hear not only criticism but some praise for the health service from Opposition Members.

Throughout the country, the Government have achieved their prime objective for the health service of putting patients first. The health service in London and elsewhere must be about providing the best possible health care within the resources of our nation and not about working for the entrenched interests of various bodies in the health service. The health service does not exist to serve the interests of those who work for it, although as a responsible employer it must take into account best employment practices.

I therefore approach reform of the health service in London rather differently from Opposition Members, but I am glad that they at least appear to accept that there is a case for doing something about the health service in London and that reforms are necessary. We can all agree that the state of the health service is not acceptable and that we wish to see improvements and changes made.

Change in itself can be disturbing. For example, it can result in the loss of facilities that people have grown used to. Sometimes decisions will have to be taken that will result in the loss of institutions that we have grown used to. I recognise the point that my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke) made—that our venerable institutions of health care in central London have served the nation well for 800 years, but that population patterns change and so the health service must not be too attached to buildings or to patterns of health care that were relevant in the last century and up until the second world war, when the population density of central London was very high.

People have moved out to Wood Green, Edmonton, Chingford, Bromley and Croydon, where the population density is now much higher yet the provision of health care has not followed that population. As an outer London Member of Parliament, I am concerned to ensure that we get our fair share of resources and I was excited about the reforms, which proposed moving resources to where people live.

Mr. Peter Bottomley (Eltham)

Further to the point that my hon. Friend is developing, which applied mainly to acute services, does he agree that one of the problems in inner London, which has been identified in many reports over decades, is that inner Londoners have been suffering from an absence of community services of any quality and that GP services do not match those that outer Londoners have taken for granted?

Dr. Twinn

Indeed. I sometimes have difficulty with the distinction between inner and outer London. I have never accepted that there is such a concept as the inner city, which is deprived, and the suburbs, which are not deprived. As a planner who formerly lectured in town planning, I knocked my head against the brick wall of Government and fellow planners who grasped simple ideas of the inner city and consequently built their policies around a misguided concept. My constituency is part of the industrial Lea valley, but inner-city factors extend out beyond my constituency into the Enfield, North constituency, areas of which are, in effect, inner-city areas.

One of the reforms in London has increased spending. The Government considered where resources should be put, and money is being put into primary care. I want much better primary care for my constituents, and investment is beginning to be made in GP practices and community health facilities. The hon. Member for Hornsey and Wood Green (Mrs. Roche) mentioned the accident and emergency department at North Middlesex hospital, which has been under threat, but I am pleased that the health authority is funding a GP for the department so that people who, perhaps wrongly, have looked to their general hospitals for primary health care can now see a GP and not take up the scarce resources of specialists in accident and emergency, which are needed for people who are genuinely suffering trauma from accidents or emergencies.

I should like those facilities to be expanded. At present, they are available only during the day. I recently visited North Middlesex hospital late on a Saturday night to see how it was working. Many of the patients to whom I spoke were waiting to be seen by specialists, but they could have been seen by a practice nurse or a GP working late at night, rather than wasting the time of people who are highly trained in dealing with accidents on the M25, the A10 or the north circular road, all of which the hospital serves.

I am pleased that as a result of our reforms money is beginning to follow the patient. In London, Bart's is regarded as a local hospital as well as a national teaching and specialist hospital. I was pleased recently to accept an invitation from Bart's to attend the North Middlesex hospital, where it has opened a clinic for renal treatment. Patients who previously had to troop down to central London for dialysis can now be treated at the North Middlesex. That is a welcome move. I hope that soon clinicians will follow and Bart's patients will be able to see their consultants at the North Middlesex. There is a great future for Bart's in moving out to the community, serving people who used to look naturally to it as their first choice but who can now look to hospitals such as North Middlesex, where the expertise of Bart's can be provided without losing the specialist nature of the Bart's team who, working together, make a special contribution to health care in London.

Teaching hospitals are not always on the side of the angels in these matters. A few years ago, I came to the House of Commons to argue for the protection of our local radiotherapy department at North Middlesex hospital. It was under threat because one of the large teaching hospitals in London believed that it should have all the money spent on itself. I am pleased to say that the Department of Health and Ministers listened to our arguments, so instead of my constituents and those of the hon. Member for Hornsey and Wood Green being dragged daily on hazardous ambulance trips to London they can have their radiotherapy at the North Middlesex, where facilities have been invested in and expanded. I am grateful to the Department for doing that.

Money is going to where patients live, but perhaps the House will forgive me if I deal with the point that the hon. Member for Hornsey and Wood Green made about accident and emergency provision in north London. Two accident and emergency departments cover my constituency. Chase Farm hospital, on the green belt borders in north Enfield, covers a large area of north London, extending out into Hertfordshire. The other department is at the North Middlesex, which is in my constituency but on the border with Tottenham. It serves the population of Tottenham, Wood Green, and Palmers Green, which is in the constituency of the Secretary of State for Employment, my right hon. Friend the Member for Enfield, Southgate (Mr. Portillo). It also covers areas of east London and Essex, where the north circular road provides speedy access to the accident and emergency department, and it will be even speedier when investment in the north circular road improvements is complete and my constituency is again open for business.

I was worried when I heard that the New River health authority, which is a monopoly purchaser—there is no other choice for hospitals—decided that two accident and emergency units were unnecessary and that one would suffice. I must say that I am not critical of reports in general. It is important to examine the provision of health care objectively and to see the facts and figures, although we have not been able to do so in this case. I look forward with interest to seeing the report. I suspect that, had the report been conducted in-house by the national health service, it would have cost a great deal more than has been charged by the private sector. The specialist knowledge of the firms involved means that they can make a useful contribution to the health service. However, I do not believe that the two accident and emergency departments cover the same area.

One of the problems that has bedevilled the national health service for many years has been the regional, district and area boundaries. Some of the more ludicrous locational decisions about hospitals in the London region have been made because there were four Thames regions whose boundaries have been treated as though they were international divides. Investment was sometimes made in hospitals close to regional borders, and it seems that the Department of Health has not exercised due care and attention in relation to the planning of hospitals in the London region for many years. That has been true under Governments of both parties. We now have only two Thames regions, so the problems may diminish. However, I am not convinced that the north-south divide in London will not lead to some unfortunate decisions about which teaching hospitals should or should not survive. I hope that the Minister will be able to clarify that point.

I believe that we are about to see the same mistakes being made by purchasers as were made by the regions. The New River health authority, which covers the two London boroughs of Haringey and Enfield, is treating its boundaries as all-important and is behaving as though its hospitals did not provide services to people from elsewhere. If the Minister is to allow the New River health authority to make decisions about accident and emergency provision in my constituency, without reference to the services that can and should be provided to a much wider area, we shall lose the services of an accident and emergency department which should not be lost.

I welcome my hon. Friend the Minister of State to his new post and ask him to give an undertaking that no purchaser—let alone the New River health authority—will be allowed to make such decisions without a strategic review being made of services throughout the entire London region. I am talking not only about Greater London but about a much wider area. Sick people do not recognise health authority boundaries, although sick minds may sometimes do so when taking planning decisions. However, I cannot ignore my training as a planner, the interests of my constituents or my common sense, which all tell me that the care of London is being planned in a nonsensical way.

Although I broadly welcome the reforms in London—I am not against the Government moving money and resources to outer London hospitals, and I am very much in favour of co-operation between outer London hospitals and centres of excellence such as Bart's—I want the Government to exercise restraint and ensure the sensible planning of facilities in outer London.

11.13 am

Mr. Alan Keen (Feltham and Heston)

I congratulate my hon. Friend the Member for Leyton (Mr. Cohen) on securing this debate. However, bearing in mind the Government's record on listening, I could not help thinking that he might as well have been speaking in an obscure language from the "Orient" for all the notice that the Minister will take of his well-crafted speech.

I shall speak a little about my local hospitals in west London, make a few points about the very important hospitals in central London, and then make one, or two general points.

My constituency contains no hospitals, but it is very well served by Ashford hospital, which is about half a mile to the west. I compliment the staff and management of that hospital on the service that they provide for the public.

I should like to remind the House how trust hospitals were formed. Ashford hospital, which I presume was following Government guidelines, held consultative meetings to ask the public whether they wished it to become a trust. At those three meetings, the vote was overwhelmingly against trust status, but the hospital proceeded to form a trust board.

I made several points at all of those meetings, and asked whether, before the issue was decided, we could see the business plan that was being drawn up. I was told that we could not, because businesses did not allow competitors to see plans. Although I could understand why ICI would not show its business plans to Du Pont, I pointed out that the shareholders in the health service were the general public, who were paying for it and were entitled to see those plans.

Co-operation and partnership between hospitals is surely more productive than drawing up secret plans and they have to be more productive than one local hospital seeing how it can best damage another in order to keep itself to the fore.

I asked several other questions to which I received no satisfactory answer. At the final meeting held at Ashford hospital, there were only 20 votes for trust status, and about 90 against. One of those who voted in favour was the chairman of the local health authority. She was sitting with a group of other people, who I presume were also managers in the local health authority. I calculate that probably only three members of the public voted for trust status, and that all the 90 who voted against were members of the public. However, that fact was not taken into account, and Ashford became a trust hospital.

We thank goodness that the hospital is still going strong, and credit for that is in some measure due to the hon. Member for Spelthorne (Mr. Wilshire). When the Government were trying to stop the hospital signing a contract for building work, after it had sold part of the land for a Tesco development, he told the hospital to go ahead and sign the contract, and not take too much notice of the Government. We thank him for that.

Ashford was not a strong hospital and we feared that competition would reduce its status and set it on a slippery downward slope. Our fears were strengthened when the health authority later laughingly undertook consultation to ask whether Ashford should be transferred from North West Thames health authority to Surrey. Of course, the answer was an overwhelming no. We felt that the North West Thames authority purchasers' loyalties to Ashford would diminish, and that Ashford would not enjoy any loyalty from Surrey.

It was not long before we discovered that Ashford hospital was under great threat from St. Peter's hospital in Surrey. My son was born there 24 years ago. I lived in Surrey at that time, but I did not know where St. Peter's was until I had to make my first visit.

My constituents who do not have their own transport would find it impossible to get to St. Peter's. Thanks to a marvellous campaign by people in Surrey and in my area, both hospitals are now to be kept open. It is vital that people have accident and emergency services, but it is just as important that they have a local hospital, because one of the main factors in patients' recovery—especially that of older people—is visits from partners and relatives. Hospitals must be based where the patients are, not where the money goes.

The hon. Member for Edmonton (Dr. Twinn) says that he has found that money follows the patients. From at least half a dozen letters in the past two years, I know that that is not, unfortunately, always the case. Often the patient has to follow the money. I have had letters explaining that relatives who have a serious illness desperately want to be treated in a hospital in my area because that is where their family reside. Their specialists want them to be treated in the area and are happy to take them on, but the money is not available from their home base for them to transfer. Too often it is a case of patients having to follow money rather than the other way round.

I have been extremely disappointed to find that not one of the directors on the board of the Ashford hospital trust lives in my constituency, despite the fact that at least one third of the patients at the hospital come from the constituency. Not one director lives in the borough of Hounslow, an even wider area. If a public limited company appoints a non-executive director to its board, it appoints him or her to represent the shareholders. If the Prudential appoints somebody, his or her role is to look after the Prudential shareholders. I remind the Minister that the shareholders in the national health service are the public and the potential patients at the hospital.

When non-executive directors are appointed to a trust board, the people concerned should be the representatives of the patients and the people in the area, not people with specialist knowledge in some aspect of management. That flaw must be corrected, and I hope that it is being corrected.

I have some slight hope. I was recently contacted by the board because there is a vacancy and the board is allowing me at least to make a recommendation. We shall find out whether any notice is taken of it.

The non-executive directors should represent patients. There is now no democracy in the health service and we desperately need representation for patients rather than the provision of extra expertise. ICI does not employ non-executive directors for its personnel and marketing needs: it employs specialists full time. That is what we want to see.

The right hon. Member for Chelsea (Mr. Scott) said how expensive Chelsea and Westminster hospital was. It was and is expensive. It is especially expensive for the other hospital that serves my constituents—the West Middlesex hospital. A good few years ago, we were promised that, when the South Middlesex site was sold—again, to Tesco—the money would go into the revamping of the West Middlesex. The hospital used to be a workhouse and some of the original buildings still remain today.

I ask the Minister to undertake, when he sums up, to hurry up the rebuilding of the West Middlesex. The hospital has raised £10 million itself by selling land. It is important that the rebuilding is pressed on with as quickly as possible, not only for the patients, but to try to recover some of the staff morale which has taken a fair dip recently as the delay has gone on and on. Following Government guidelines, the hospital raised the £10 million itself. I ask the Minister please to see whether he can hurry along the rebuilding.

The Chelsea and Westminster hospital is expensive. I have heard—I hope that the Minister can confirm this later—that the Charing Cross hospital, which serves my constituents to an extent, is being plundered for equipment which is then being moved to the Chelsea and Westminster hospital, which should never have been built, as most people recognise.

The West Middlesex hospital rebuilding programme again shows the Government's short-termism. If the £10 million can be spent, £2.5 million will be saved on running costs. At the moment, there is a need to duplicate services in different parts of the hospital because it is on such a large site. We want the rebuilding to be pressed ahead with as quickly as possible.

We all know that, in many of its specialties, Hammersmith hospital is a world leader. We have seen damage to the research teams at Hammersmith because of the uncertainty of the past four or five years. We were all glad when no decision was taken to close either Charing Cross or Hammersmith; we were pleased when it was decided that they were both to be kept open. However, that has not really solved the problem.

We want a definite statement that both hospitals will remain open. We need accident and emergency facilities at both hospitals; that is vital. We must take action as quickly as possible to preserve the research teams who do work that serves the whole world, not just Britain.

I have some simple, basic points to put to the Minister in the form of questions. Why do we have to sell every piece of grass and every bit of shrubbery to raise money for further building at hospitals? Why do people at a time of greatest need have to visit hospitals where there is only concrete and brick? The hospitals could have retained some of the decent surroundings. It is a scandal that we have to sell off so much land.

What will be done to put some democracy back into the health service? What in the world is the purpose of a system that allows a health service trust—Premier Health, based in Staffordshire—to tender for the provision of community care throughout Britain? There is no doubt that, with community care, which is labour-intensive, the only savings one can make are by getting district nurses to run faster and to drive their cars faster. Community care is labour-intensive, and the labour involved is skilled labour.

The district nursing sisters have years of experience. They are often the only people who visit those in community care. General practitioners do not visit many of those patients. It is up to the community nurses to notice signs of deterioration in their patients' health or to see that things are going okay. We cannot afford to de-skill by getting rid of those experienced sisters, yet that is happening throughout the country, and it will happen where Premier Health is quoting.

We cannot afford to replace those community nurses by newly qualified nurses coming out of hospitals. We need those skilled district nurses. I ask the Minister to give us a quick answer to those questions when he replies.

11.27 am

Sir Michael Neubert (Romford)

The speeches this morning by my right hon. Friends the Members for City of London and Westminster, South (Mr. Brooke) and for Chelsea (Mr. Scott) show what an access of strength and influence has come to central London as a result of my right hon. Friends' return to these Benches. I am indebted to you, Mr. Deputy Speaker, for giving me the opportunity, as an outer London Member, to contribute to this important debate.

There is no doubt that the health service is of prime concern to my constituents in Romford, second only to their economic well-being. It is no surprise that, in consequence, we have a very full attendance of London Members for this debate initiated by the hon. Member for Leyton (Mr. Cohen), to whom we must be grateful for providing this relatively rare opportunity to discuss London strategy.

My contribution relates to Oldchurch. For most of my constituents, the national health service is represented and embodied by Oldchurch hospital. There is generally a high degree of satisfaction with the health service in my part of London. It is just as well there is. I have to tell my hon. Friend the Minister, whom I also welcome to his new responsibilities this morning, that for many people the health service is the criterion by which they judge the Government.

My constituents generally have few complaints about the treatment they receive under the NHS. The complaints I receive are in the main about their failure to get treatment sufficiently soon. There are still two or three specialties in which there are unacceptably long waiting lists in my part of the world.

Unhappily, I have to report that Oldchurch is, once again, under threat, as it has been for many years. Oldchurch is the district general hospital which serves not only my constituency, but the constituency of Hornchurch next door and the London borough of Barking and Dagenham, as well as other parts of Havering. There is no question but that its future has been under challenge for some considerable time.

The most recent evidence was that, after the Tomlinson report, when surveys were initiated with regard to some of the major specialties, especially cancer and neuro-science, both working parties proceeded on the assumption that Oldchurch hospital was to close. I do not know where that information came from—I have not been able to pin it down—but it seems likely to be true, because some people in the higher reaches of the hospital administration, perhaps at regional level, have been dead set against Oldchurch hospital for decades and are trying to plant that uncertainty in the minds of those who are adjudicating on how the future health service of London should be arranged.

As a consequence, it is proposed that Oldchurch is to lose both the cancer and the neuro-science services, as well as—now—its accident and emergency unit. It is on that point that I wish to make my relatively brief speech.

I can be brief because I had the good fortune to initiate an Adjournment debate on 18 July, which, in parliamentary terms, is only a few days' sittings ago. I also had the opportunity to meet the Minister, my hon. Friend the Member for Bolton, West (Mr. Sackville) two days later. As a result of that, and in deference to your wishes, Mr. Deputy Speaker, I can be brief. I shall also be narrow, because it is a matter that affects our part of London. It is one more piece in the jigsaw of the whole picture of London, and I am glad to be able to talk about it.

When one examines the issue of casualty services, one can see that there is a general strategy, which had not, as far as I know, been announced, but which was put in place by a series of decisions and pending decisions. An article in the Evening Standard on 23 August revealed: Managers have already closed 23 London casualty units over the last eight years,". It is therefore no wonder that this morning one of the recurrent themes is the future of accident and emergency services in London.

It concerns me that, apparently, the strategy is determined by a recommendation, made in 1988 by the Royal College of Surgeons in England, that there should be only one hospital with an accident and emergency unit in each NHS district. Whatever the technical, medical or professional reasons for that proposition, it is obviously ultimately arbitrary, because health districts vary in size, in character, in population density and in health need.

In our case, in Havering, we were part of the Barking, Havering and Brentwood health district. That was one of the largest in the country, certainly the largest district in London. Even now, with the excision of Brentwood, which has gone into Essex, the Havering hospitals trust claims to serve 500,000 people. It seems arbitrary to suggest that that figure should warrant only one accident and emergency unit. I warn the Minister against that sort of academic calculation, because it militates against the best interests of patients at local level.

If I talk about the distribution of health need, it is quite clear, from examination of the Barking and Havering health district, that the health need is greatly concentrated in the west, and not in the east where it is proposed that there should now be one accident and emergency unit in our district. Of course it is true that there are the considerations of casualty services being provided at King George hospital in Ilford, but that will take people well out of their way in many cases of accident and emergency.

The professional arguments are well understood, and can be seen from a professional point of view. It is to have the highest standards of equipment and the greatest number of staff of different skills available in one place, but in accident and emergency, above all, time is of the essence. The crux of the matter lies in ease of access by road and proximity to the main centres of population. That should be the overriding consideration when deciding on the location of a casualty unit.

To date, the community health council has reluctantly agreed that there should be one accident and emergency unit only in our district. The current argument, which is fierce and controversial, is about where that unit should be—whether at Harold Wood in the east of the district, on the periphery of the area of population, or at Oldchurch hospital, which has traditionally served the main bulk of the population and, certainly, has been closest to the health need of the district for so many years.

I urge my hon. Friend the Minister and our right hon. Friend the Secretary of State to pay heed to the recent letter from the chairman of the CHC, who pointed out the future prospects for demographic change in our area.

I see that the hon. Members for Barking (Ms Hodge) and for Dagenham (Ms Church) are present this morning. Perhaps they will be seeking to catch your eye, Mr. Deputy Speaker, and they may be able to speak more knowledgably about this matter, but I am advised that the Barking Reach development, which is part of the Thames Gate development, will result in an increase of 18,000 residents in that part of our health district. Furthermore, there is massive industrial development planned for Rainham.

It is therefore important that, when making a decision—we understand that a decision on that particular issue is imminent—those factors are taken into account as well as the access. Harold Wood is ill served by the network of roads approaching it, and it would be necessary for better access to be provided. That cannot, apparently, be taken for granted, because I learned this morning from representatives of the London borough of Havering, which would be the planning authority concerned, that the council would have technical objections to what is proposed for Harold Wood hospital, which may need to be tested at a public inquiry.

In consequence, the borough has sought an urgent meeting with the Secretary of State, at which Members of Parliament representing the district would be present, including my hon. Friend the Member for Hornchurch (Mr. Squire), whose ministerial role prohibits him from taking part in the debate, but whose support for the retention of Oldchurch is well known and highly publicised. I hope that that request for a meeting may be considered favourably, because the matters concerned are of the utmost importance to us and our constituents.

I return to the point about the strategy being based on an academic calculation. It seems quite wrong that it should be so formulaic an approach. To come up with the idea that there should be one accident and emergency unit for each district is a transparently artificial, desk-based exercise with a nice, neat conclusion reached by vested interest. The vast majority of the public, the CHC, the local authorities, even the medical staff at Oldchurch hospital itself are in favour—strongly in favour—of those services being retained at Oldchurch hospital.

I hope that that will weigh heavily in the balance. One thing is quite clear about such proposals to reduce the number of units: they do not put on the balance sheet the cost, effort and time involved in making people travel further to receive their services. That is a weakness in the system, because it does not up show up in the figures, yet it is a reality to people, because especially with accident and emergency services—it is a cliché—we are talking literally about life and death. It surely would be regrettable, not to say irresponsible, if, as a result of placing casualty services further away from people whom they are meant to serve, some people should suffer the ultimate penalty and die.

I hope that my remarks will be added to those which have already been made as representations to Ministers on this issue and that the decision may be favourable to Oldchurch. On the merits of location, if location is given its high priority in the consideration, there can be no doubt that Oldchurch it must be.

11.38 am

Ms Margaret Hodge (Barking)

Thank you, Mr. Deputy Speaker, for enabling me to participate at this stage in the debate as I currently feel in need of the services of the national health service.

I want to address the specific problems about which the hon. Member for Romford (Sir M. Neubert) talked in relation to my constituency. But first, as a relatively new hon. Member, I should like to reflect a little on my recent experience of the London health service, as a non-executive director of University College hospital. The chaos and the absurdity of the Government's health reforms were a nightmare for any of us involved in trying to keep the services on the ground going in spite of those reforms.

We all know that an unregulated market in health is crazy. We know that it is particularly crazy in London. When I was a non-executive director at UCH, I had to live with the essential contradiction in the Government's policy and at the heart of the Conservative approach to the national health service: we had a market in theory and Tomlinson in practice.

For UCH, that meant that we lived from crisis to crisis. We were subjected to constant indecision, constant changing of the goalposts and instant planning on the back of an envelope by weak and inconsistent Ministers. The last thing I was able to do as a non-executive director was examine the quality of the health care provided for the patients in the hospital and the value for money provided by the resources expended there.

We lived under crisis management. Was the hospital going to survive? Was it going to be merged with the Royal Free? What was going to happen to Great Ormond Street and UCH? Which specialties, if any, were we going to be left with after the specialties review? When Camden and Islington district health authority threatened to withdraw its contract, we again wondered whether we were going to survive.

The crises did not serve the interests of the patients or the Treasury. They were simply manufactured from the absurd reforms, and they had no purpose. In theory, the reforms are supposed to improve transparency and accountability for the public expenditure on health. In practice, our health service is forced by the reforms to work behind a veil of secrecy, and the reforms have failed in terms of their own objectives.

The first item on the agenda at my first meeting as a member of the UCH board was whether we should have our meetings in public or in private. I felt somewhat inhibited about contributing, as it was my first meeting. At the end of a lengthy debate on the matter, the chairperson asked me for my views. I said that, as we were spending about £20 million, it seemed to me that it might be a good idea to be accountable for that, and to hold the meetings in public. At that point, the other members of the committee said, "We can't do that, because the Royal Free would know what we were doing." That shows the absurdity of the situation.

In theory, the reforms are supposed to put patients at the centre. In practice, the patients' interests were pushed to the bottom of the agenda in the way in which we were forced to manage UCH. Our customer was not the patient but the district health authority. Our prime concern was either the district health authority or the Audit Commission. Nowhere in the provider-purchaser split were the interests of the patients properly reflected. That appalling part of the strategy leaves the user—the consumer—of services out on a limb.

As a representative of the customer on the UCH board, I constantly had to remind my colleagues that the district health authority did not necessarily reflect the views of local residents and users. I also had to say that the Audit Commission's indicators were not always the most appropriate for people in my locality.

Let me give an example to show how absurd the system was. When Camden and Islington district health authority threatened to withdraw the contract for accident and emergency provision at UCH, the chief executive decided to hold several consultative meetings. She went to a consultative meeting in Finsbury and began to talk about the needs of Finsbury Park down there in Finsbury. That was the extent of her knowledge and understanding of the local community whose interests she was supposed to represent.

My next criticism as a non-executive director of UCH relates to value for money. The last thing we were able to achieve in our capacity as non-executive directors was value for money for the resources over which we had control. Let me give examples. A very good day surgery unit has been established at what used to be Middlesex hospital. We had to staff it fully, but it was used at only 50 per cent. capacity, because there were insufficient purchasers around with the resources to take advantage of that brand new facility. University College hospital was spending money on the unit, the beds were lying empty, and the need was out there in the community. The last thing that reflected was value for money.

The reforms also failed to address issues such as how to ensure appropriate staffing for the hospital one is running. Those are the issues that Ministers should address. University College hospital, Middlesex was the result of a merger between Elizabeth Garrett Anderson, the Middlesex and UCH. We therefore had one gynaecological unit merged from three. However, because of the absurdity of the system under which we had to operate, we were unable to ensure that we could rid ourselves of the 15 consultants who worked in the merged hospital, although there was a need for only three consultants, given the number of beds that were finally available.

If Ministers addressed the real issues which constrain decent value for money, we might obtain better value instead of concentrating on the absurd reforms which achieve very little in respect of putting value at the heart of the system in London and patients first.

I thought that things could not be as bad elsewhere in London until I came to Barking. As the Member for Barking, I know that the state of the national health service in my locality is the issue of greatest concern to the greatest number of my constituents, and it is a terrible verdict on the Government's lack of care for the people whom the Government are supposed to represent. Bluntly, as they have become prisoners of their own dogma, the Government are betraying thousands of my constituents. My first duty as Member for Barking was to try to come to terms with the issues around what I gather from the hon. Member for Romford (Sir M. Neubert) is a long threat to the accident and emergency unit at Oldchurch hospital. The absurdity of the situation is that I still cannot discover whom I should really be talking to, to establish who is responsible for the decision.

My hon. Friend the Member for Dagenham (Ms Church) and I have tried—I believe we have probably managed it now—to meet all the components of the health service in our area. We have been to the district health authority, the hospital trusts, the regional health authorities, Ministers and the family health services authorities. However, it is unclear who is really driving the decision process.

Is it the hospital trust or the district health authority? Is it the regional health authority or is it the Minister? Responsibility is unclear, and accountability non-existent. The complex web of bureaucracy through which I have had to wade in trying to tackle that constituency issue is absurd. The reforms have created fragmentation, which in turn is creating chaos.

Before I refer further to the specifics of the Oldchurch accident and emergency unit, I want to refer to another issue which arose from the case load in my surgery. This issue again shows how absurd it is to proclaim that the health service reforms ensure that the money follows the patient.

I was surprised when people came to my constituency surgery and told me that they could no longer attend the London Homeopathic hospital, when they had been attending it for treatment for 20 years. When I inquired into this, it emerged that an individual in the district health authority—I believe I got to the bottom of this one—simply did not believe that homeopathy worked.

That is fine for that individual. However, for my constituents who believed that the homeopathic treatment was helping them to deal with long-term problems and illnesses to have access to that service constrained by the prejudice of a person whom Ministers have put in charge of taking decisions on their behalf is just nuts.

I ask the Minister to intervene in that instance, because he must have some responsibility somewhere along the line. He should instruct the district health authority to reinstate choice for my constituents in Barking, so that they can take advantage of the services offered by the London Homeopathic hospital.

In July, the hon. Member for Romford initiated a debate on the threatened closure of the accident and emergency unit at Oldchurch hospital. In that debate and in subsequent meetings with Ministers and the regional health authority, we were assured that no action would be taken to prejudge the decision, first, on whether there should be only one accident and emergency unit in that area and, secondly, on whether it should be located at Oldchurch. At a meeting, the regional health authority said that it was not satisfied that it could decide because it was not satisfied that there had been a proper audit of usage in the area. It was not satisfied that the proposed minor injuries unit would have capacity to deal with sufficiently serious cases to complement the existence of only one accident and emergency unit. It was not satisfied that traffic management facilities would enable the hospital accident and emergency unit to be located at Harold Wood hospital.

I went away on my summer holiday thinking that we had bought a period when there could be rational debate, first, on whether one accident and emergency unit would be sufficient for the area and, secondly, on whether it would be appropriate to close the unit at Oldchurch. Suddenly, in August, the local hospital trust closed the accident and emergency unit at Harold Wood and started to spend a cool £6 million on improving facilities, one assumes subsequently to close the accident and emergency unit at Oldchurch. Somewhere, someone along the line made the decision that we thought that we could debate: it was pre-empted, and public money—our money—is being spent on improvements at Harold Wood, one assumes with the sole purpose of closing the accident and emergency unit at Oldchurch. My postbag and my surgery are inundated with cases relating not to the quality of health care in the health service but to access to such health care.

I agree with the hon. Member for Romford, who said that the allocation of one hospital for 500,000 people is completely arbitrary. Again, someone has secretly decided, one assumes in ministerial meetings, that we in London need only one hospital for every 500,000 people. I was interested to hear the hon. Member for Edmonton (Dr. Twinn) refer to a similar set of proposals being discussed by the New River authority. Where is the justification for allocating one district hospital for 500,000 people? How can that meet the health needs of people in London?

If there is such justification, why can we not see it and debate it in public so that London Members can play their part in determining appropriate hospital provision for the health care of Londoners? For my part of London, one hospital for 500,000 people is not appropriate. The proposal is to close the accident and emergency unit at Oldchurch, despite the view that it does not mean the end of Oldchurch hospital, and I am convinced that, in five years' time, hon. Members will discuss the death of Oldchurch hospital.

The proposed closure of the accident and emergency unit at Oldchurch hospital comes after the death of other hospitals in the area. In my constituency, we have no hospital at all—Barking hospital has been closed. My predecessor, Jo Richardson, fought hard to save that hospital. It was built out of the voluntary effort of local people. It is unacceptable that they should face the closure, in 10 years, of yet another hospital in the area, involving them in travelling greater distances and having worse facilities.

I agree with the hon. Member for Romford on another point. If, as it appears, Ministers have decided to locate the accident and emergency unit at Harold Wood, they will implement Dr. Hart's inverse care law. We will have the hospital located where it is least needed, and where need is greatest there will be no hospital provision.

I am very keen to improve primary health facilities in my constituency. At present, they are appalling. For example, we have three times the national average of single-handed practices—32 per cent. Also, 25 per cent. of our GPs have lists of more than 2,000 patients, which is more than twice the national average, and 67 per cent. of our local practices are classified as poor. Only five are classified as good, and none fits the category of best. Despite those poor primary care facilities and despite the long time that it will take to improve them, even if the investment is available, we will face the immediate closure of one alternative to primary health care, which is an accident and emergency unit in our area.

The proposed minor injuries unit will not be an appropriate substitute. At the meetings which my hon. Friend the Member for Dagenham and I attended, it was interesting to note that different bits of the health service had different views of what role the minor injuries unit would fulfil. After we talked to the regional health authority, I thought that a broken leg could be treated at the minor injuries unit. When I talked to the district health authority, it told me, "No way. The only thing that could happen is that a plaster could be put on a scratch." They are two different facilities. If those bits of the health service that are charged with making the decision cannot agree what purposes the minor injuries unit should fulfil, how can they decide to close the accident and emergency unit at Oldchurch without being secure in the knowledge that there is proper alternative provision?

People involved in health care in the area have placed King George's hospital on the agenda to treat my constituents who go to Oldchurch hospital. On 19 September, the Secretary of State for Health visited Ilford Conservatives. She spoke about King George's hospital being a shining example of excellence. That night, patients were turned away and ambulances were diverted. Patients had to wait 10 hours at the accident and emergency unit at King George's hospital. In her embarrassment, the Secretary of State has since ordered an inquiry into what is happening. She would do well to start by considering the weekend of 15 and 16 October. Again, the accident and emergency unit was closed, and again a patient had to wait 22 hours before being seen. That has occurred in the context of the Havering hospitals trust having the worst performance in respect of seeing people within the terms of the patients charter, that is, within five minutes of their arriving at an accident and emergency unit.

We also know of the chaos in the London ambulance service. The ambulance service could not cope with the greater distances that it would have to cover if we closed that hospital. The ambulance service has said that the time taken to reach hospital, if Oldchurch A and E is closed, will increase by 72 per cent., from 11 minutes to 19 minutes.

It is difficult to choose one case out of my case load to highlight the crises in east London, but there is the terrible case of an elderly man who has lung cancer and is bedridden. The ambulance arrived at 8 o'clock in the morning to take him to hospital for treatment. It was decided that he could not be taken because the ambulance had a one-person crew and two people were needed to get the wheelchair into the ambulance. Eventually, he was picked up at 11.30 am, having waited from 8 o'clock in the morning. After he had had an X-ray, he was ready to go back home at about 1.50 pm. He waited for seven and a half hours to be taken home in his wheelchair. His feet were bleeding from resting on the footplate for so long. At 9.30 pm, a St. John ambulance with a one-person crew took him home. In the end, neighbours had to assist in getting the gentleman out of the ambulance and into his bed.

The proposals for our part of east London are a disaster for my constituents. My constituency has a preponderance of elderly people. They are just the people who require hospital treatment more than any other sector of the population. I represent a preponderance of people who are less well off. They do not have cars to take them to hospitals and the ambulances are not there to provide the service. As I go around the constituency, I find that they are giving up on the health service. They cannot afford to buy privately. They are giving up on health care because they cannot gain access to it. Sadly, they are not as vocal as people elsewhere in London; but the fact that they are not vocal does not make their need any less.

The Government's approach is blinkered and short term. It is failing Londoners and it is failing my constituents. I urge the Minister to call a halt to all these absurd proposals, particularly those on the closure of the accident and emergency unit at Oldchurch hospital, and to institute a commonsense review of health provision in the capital so that we provide value for money and properly meet the needs of Londoners.

12.1 pm

Mr. John Whittingdale (Colchester, South and Maldon)

Unlike the hon. Members who have spoken so far in the debate, I am not a London Member. My constituency lies about 60 miles from London on the Essex coast. However, I make no apology for speaking. Despite the distance from London, my constituency still lies in the North Thames regional health authority area. As a result, the developments affecting health care in London have a direct bearing on the resources and facilities that are available to my constituents in north Essex.

My hon. Friend the Member for Edmonton (Dr. Twinn) said that one of the reasons why we are having to discuss changes in London's health care is the steady migration of population out of London. In the past 30 years, London's population has fallen by 1 million. Many people have decided to move out of the inner cities and have gone into the outer London suburbs, as represented by my hon. Friends the Members for Edmonton and for Romford (Sir M. Neubert).

Later in life, however, those people have often decided to move out further still and they have come to settle in constituencies such as mine in north Essex. The result of that has been that the population has grown in my area. A large proportion of the people coming into it are elderly people. They have come to retire in places such as Mersea and Maldon. That has put additional strain on the local health authority, which has had to cope with both a growing population and an increasingly elderly population. It should be borne in mind that the average health care cost of someone over 75 years of age is four times the average health care cost of someone over 45.

Unfortunately, the allocation of resources in the national health service has not followed the movement of patients. In the Thames regional health authorities, there has been a historical bias towards London at the expense of outer areas. Despite its falling population, London has received a disproportionate amount of resources. That has led to persistent underfunding in outer areas such as mine in north Essex. As a result, we have excessive waiting lists in north Essex for many treatments, particularly orthopaedic treatment and the treatment of cataracts.

After a lengthy wait to see a consultant, a further wait of 15 to 18 months has been all too common. Having taken evidence in the Health Select Committee, I know that that is not the case elsewhere. Hon. Members were told that Dorset has a maximum waiting period from the point of general practitioner referral of about 35 weeks. However, a GP practising in Wimbledon and Tooting told us that, as a result of competitive contracting, his patients do not have to wait for elective surgery and no patient waits for more than six weeks to see a consultant.

Mr. Jenkin

Speaking for a constituency that neighbours that of my hon. Friend and that is in the same health authority, I very much share the concerns that he has expressed. Is it not the case that, because we are in a Thames region, before the introduction of capitation funding, which has gone some way to help us, our allocation per head was about 10 per cent. below that of the neighbouring authority in south Southwark, which is not in the Thames region and does not suffer from the same London effect?

Mr. Whittingdale

I am grateful to my hon. Friend the Member for Colchester, North (Mr. Jenkin) He is right. Indeed, he has anticipated a point that I was going to make later on and so saved me from having to do so.

As my hon. Friend said, the move towards capitation funding as a result of NHS reforms has helped. He and my hon. Friend the Member for Chelmsford (Mr. Burns)—both of whom I am pleased to see here today—joined me in going to see the Secretary of State for Health to raise the need to divert more resources towards areas such as our own. She gave us an assurance that we would move to 98 per cent. of capitation target within three years. We have already reached that target as set by the health region's formula. That meant that we also received an extra £1.2 million last year and £1.4 million this year to reduce waiting lists, which is extremely welcome.

North Essex, however, has in the past continued to suffer as a result of the variation of the national formula employed by North-East Thames regional health authority. Although the formula employed to distribute resources between regional health authorities has only a small factor to take account of social deprivation, North-East Thames has added its own weighting factors to distribute in the region. Those factors have strengthened the social deprivation allowance and an additional homeless factor has skewed the distribution of resources still further towards London.

I do not dispute the need to take account of social deprivation in allocating resources in the health service. The former North-East Thames health authority included Tower Hamlets, Hackney and Newham, some of the most deprived areas in the country. I know from evidence that the Health Select Committee heard when examining mental health that increased social deprivation increases demand on health resources, particularly for the mental health service. However, the effect of that formula has been that outlying areas such as north Essex have, in effect, lost out twice. North-East Thames regional health authority does not receive the increased allocation of funds to reflect the fact that it contains deprived areas. In allocating its own funds, however, it does take account of that. As a result, outlying regions are penalised twice over.

If the national formula were used to distribute resources in the region, or if a regional formula were used to allocate funds nationally, north Essex would gain. As my hon. Friend the Member for Colchester, North said, that is most dramatically shown by comparing our region's level of resources with that of our neighbour, which is not in the Thames region. The position has improved as a result of the move to capitation funding, which has allowed waiting lists to fall, but it would be improved still further if we could move away from the current arrangements.

I believe that the Department of Health is considering a national single formula for capitation funding across the country. I welcome that and I urge the Minister to ensure that it is introduced as soon as possible.

Understandably, the specialty reviews have occupied most of the time today. As has happened, I suspect, to many hon. Members, several constituents came to see me on Monday to ask me about the future of Bart's hospital. They had all received excellent treatment at Bart's and I understand the loyalty that they feel to that hospital and their wish to see it continue. Similarly, I have had contacts from other constituents who have received treatment at the London chest hospital, the Hammersmith hospital and Royal Marsden hospital. All of them feel the same degree of loyalty towards those hospitals. I had to say to them, however, that I believed that it was wrong for them to have to come in the first place to inner-London hospitals to receive treatment.

I recently visited Bart's with members of the Select Committee and on arrival I saw an ambulance from the Essex ambulance service delivering a patient for treatment. Why do my constituents have to travel more than 60 miles into London to receive specialist treatment? The answer is that for cancer treatment inner London has 13 centres while Essex has two. Inner London has 14 cardiac treatment centres but there is none in Essex. London has 11 centres for renal treatment and Essex has one and for plastic surgery London has nine centres while there is only one in Essex. There are 13 centres in inner London for neuro-sciences and none at all in Essex.

One of the reasons for the shortage of beds in London, despite the decline in the population, is that my constituents and those in areas similar to mine have to travel to London to obtain specialist treatment. But it is often far more expensive to provide treatment in London than outside it. I strongly welcome the publication of the specialty reviews. They will result in streamlining London's specialist services and I hope that they will also release resources to allow the provision of specialist services in Essex where many of London's patients live.

It has been suggested that a new cancer centre and possibly a cardiac centre should be established in Essex where both are badly needed. In the case of Bart's, it must make sense to consolidate on one or two sites the services that are currently provided on three. I welcome the formation of the joint trust covering the three hospitals and it must also be right that the management of those hospitals and the people who work in them should be asked to come up with recommendations about how the consolidation is to be achieved.

Another recommendation of the specialist reviews on the future of neuro-sciences at Oldchurch hospital has been mentioned by my hon. Friend the Member for Romford and by the hon. Member for Barking (Ms Hodge). I recently visited that hospital to see the neuro-sciences department there and I pay tribute to its highly skilled team. However, the report of the specialist reviews recommends that the unit should be closed and the service relocated to the Royal London hospital at Whitechapel. That would move it even further away from my constituents and that would be contrary to the whole thrust of the Tomlinson proposals and what I thought we were trying to achieve. It would be ludicrous to move the centre further still into inner London. If Oldchurch is unsuitable in the long term for a neuro-sciences unit, it would be make far more sense to move it out to an area such as Broomfield which is rapidly developing as a centre of excellence for health care and serves the whole of north and mid-Essex.

Mr. Jenkin

I should like to deal with the issue of cancer. Has my hon. Friend digested the Cameron report, which vindicates the principle of moving centres of excellence away from conurbations such as London and into the regions so that people such as those in Colchester could continue to be served by a cancer unit that provides radiation treatment and would not have to travel to London?

Mr. Whittingdale

I agree with my hon. Friend. We both hope to see a new cancer centre in Colchester as soon as possible.

The London reforms cannot be viewed in isolation. For too long, people in constituencies such as mine have been paying the price for the over-allocation of resources and hospital beds in London. I urge the Minister to press ahead with the reorganisation of London's health services because they will benefit both Londoners and people in outlying areas in the Thames region.

12.14 pm

Mr. Simon Hughes (Southwark and Bermondsey)

The debate is timely and the hon. Member for Leyton (Mr. Cohen) has done us a service by giving us a debate on the second anniversary of the Tomlinson report.

Mr. Clive Soley (Hammersmith)

He also provides us with many other services.

Mr. Hughes

I agree. It is three years since that report was commissioned and two years since it reported and now we must face what it implies. I welcome the contributions by the right hon. Members for City of London and Westminster, South (Mr. Brooke) and for Chelsea (Mr. Scott). Their speeches showed that when people cease to be Ministers they can speak out for their constituents much more strongly. I am sure the Minister has noted what they said about the needs of their parts of inner London. My final tribute is to another former Minister, the hon. Member for Romford (Sir M. Neubert), who made many important points about the way in which we go about planning the process of health service decisions. He spoke mainly about his part of east London, which was also mentioned by other hon. Members.

We welcome the new Minister and I hope that today's speeches will give him the flavour of the difficult issue that he has inherited and must deal with. I certainly understand the difficulties, which were highlighted by the hon. Member for Colchester, South and Maldon (Mr. Whittingdale). As he said, one of the key debates is about the fair and proper allocation of resources across the country. The other must deal with the total allocation of resources to the health service.

If the Minister looks at opinion poll evidence, whether from the Tory party research department or the general public opinion polls, he will see that the public are most preoccupied with two issues: the funding, resourcing and future of the health service and the general economic well-being of themselves and the country. People are saying very strongly that the health service needs more support and funding. We are soon coming to the second integrated Budget with its public expenditure announcements and the Minister should bat as hard as possible to ensure that health service funding is not reined back. NHS requests for funding must be supported.

Mr. Jenkin

Will the hon. Gentleman give way?

Mr. Hughes

No, because I want to ensure that everyone who wants to speak has a chance to do so.

I agree that there is waste. The hon. Member for Hornsey and Wood Green (Mrs. Roche) gave good examples of the way in which the newly structured health service produces waste rather than reduces it. But above all, the NHS must have the resources that it requires. Those resources are determined by need—that is to say, by the number of people waiting to be dealt with, whether they can be dealt with at the time when they need treatment, as the NHS intended, and whether there is capacity to deal with them properly in the GP's surgery, the local clinic or the hospital.

I hope that we can all agree that one of the lessons from the debate is that the health service, however big its budget, is still not adequately meeting the needs of an ever-aging community which obviously will make increasingly more demands.

The other difficulty that I mentioned relates to the allocation of resources. I have one general and one specific comment on those. If we all look at the figures honestly, there should not be significant dispute between those who represent London constituencies and other hon. Members. London receives more resources per capita for services such as policing and social services, as inner-city areas always do. There are all sorts of reasons for that, sometimes because of salaries and costs which are obviously higher in cities. I could quote from several parts of the Tomlinson report which make it clear that London as yet does not have the same standard of care for its patients as many other parts of the country.

Mr. Jenkin

rose—

Mr. Hughes

As I have said, I shall not give way because many hon. Members want to speak in the debate.

No one argues that there should not be adequate health care in Essex, Sussex, Surrey or Lancashire. The argument is that the people of London and those who will inevitably continue to come to London to work or to visit or because they are referred here—not because there is no alternative, but because for them London is the better alternative—should have the correct proportionate share of the cake. There are also the extra burdens that fall on the inner capital city—the homeless, rootless people on the streets, the number of people with problems of poor mental health, and other deprivation factors.

If we look at the problems honestly and use agreed facts and figures, rather than working on prejudices, there should not be tension. It is not impossible to say that London needs more resources, but also to accept that more resources are needed elsewhere. We must not have an artificial debate.

We cannot come to a proper conclusion about this until we have a fair outcome of the review of weighted capitation which is sitting in the Department. I understand that it is complicated—I have been round this course many times since I came into the House and many of us understand the range of issues involved—but we cannot fairly calculate adequate provision and the appropriate figures unless a common formula is generally agreed and endorsed as valid, to which we can all work.

That is especially important in relation to London. It is nonsensical that my constituents and our local health authority have to pay more to buy services from our local district general hospital—which happens to be Guy's—than to buy them elsewhere, simply because they happen to have been born, brought up or settled in a part of London where the land costs are higher. It is nonsense to say, "We will charge you out of existence and ship you further away because the land costs for a hospital in outer London, the midlands or wherever are cheaper." Without dealing with that unfairness, we will not solve some of the other issues.

Tomlinson recommended the setting up of the London Implementation Group to secure effective pan-London co-ordination of a restructured NHS. Without such co-ordination, we cannot make sensible decisions. We have already moved from four regions to two. However, people seem unable to debate the London health service as a whole except in this place. In addition, all the other people who make London's health decisions are appointees of the Secretary of State. If the debate is on a health authority, the debate is sometimes in public and sometimes in private; if it is by a trust, it is always in private.

One reason why the Government are in such trouble with the health service, including in London, is that they have no co-ordinating body, with consequent absence of accountability and meetings in public. If health authorities met openly and discussed these matters strategically, there could be a consensus whereby budget parameters could be set, but accountable, and local people chosen or elected to make decisions. That would cause the Government far less political difficulty and it would be a far more democratic process.

Tomlinson made three other salient introductory points. First, he envisaged that there would have to be fine tuning of his proposals. On page 1 of his report he said: The mechanism we propose will allow for fine tuning as events unfold. What the Minister is hearing is, "Please don't just go by the original proposals without modification after listening to the arguments and hearing the debate."

Secondly, Tomlinson said: We have taken it as a fundamental that the population of London must have as high a standard of general practitioner, hospital and community-based health care as the rest of the country. That is one of tests. The second is: Subject to this overriding requirement, we aim to preserve and enhance the national and international role of medical research in London and in the many other centres of the UK. That cannot be done by saying that some of the greatest institutions—in terms not of age but of excellence—should be taken out of NHS provision.

Tomlinson's third salient point, which again came in the early introductory statements, was that he was seeking to build upon consensus rather than merely devising our own blueprint for action. I say to the Minister, for heaven's sake build on consensus and do not proceed with a Government blueprint for action that does not have the consensus of patients, those who work in the health service and those whom we serve.

When considering resources and making decisions about hospitals such as Oldchurch, Bart's and Guy's, we must look not only at the pan-London picture but at the local picture. In the Guy's case, we must look at resources in south London, south-east London and inner south-east London, which have far fewer beds than the national average in terms of population. It is no good applying to a local area a principle that is, first, questionable, and secondly, does not work within the relevant immediate community. As the hon. Member for Leyton made clear, figures and facts have changed and the evidence is different. The Treasury does not base its decisions on facts that are three years old—and heaven knows, it still does not get it right often enough. I am not claiming that we shall always need the same number of beds from now until eternity, but the decisions on bed numbers must be based on accurate facts about bed numbers.

The hon. Member for Peckham (Ms Harman) and I attended the annual general meeting of the Guy's and St. Thomas's hospital trust recently. Its first annual report was produced on the day of the meeting, so no one had the opportunity to read it before then. It contained not a mention of bed figures. When I asked how many beds the trust had now, and on 1 April this year and on 1 April last year, nobody knew the answer. The trust did not know how many beds it had. That is nonsense. There must be agreed facts because we cannot make decisions about beds and expenditure in London on the basis of fallacious and outdated information or on no official information at all.

An increase in primary care in London is clearly needed. The Government have accepted that, and the London implementation zone has been set up. Many general practitioners' surgeries are poor and the quality of some general practitioners is poor. However, it is fallacious to believe that increasing expenditure and quality in primary care reduces the demand for secondary care. The evidence shows that the opposite is true. If there is better primary care, diagnosis is made earlier. More preventive health care means that more needs are identified, which then have to be referred for secondary action. It is not justified to say, "We are taking money out of the acute sector to put into the primary sector, so that means a reduction in the secondary sector."

In relation to accident and emergency provision, I hope that the Minister will please not confuse, "These are cases that could be dealt with by GPs", and "These are cases that could be better dealt with by GPs". All sorts of things can done by GPs, but that does not mean that they are things that GPs are happy to do, comfortable to do, have the equipment to do or are the best people to do. Many people will continue to need to go to accident and emergency departments for treatment and we must judge the need on that basis.

Surely the test for the Minister is whether the health service in London is working. The answer that he is hearing from hon. Members on both sides of the House is that the NHS in London is not working. The ambulance service is not working. Youngsters and old people from Tower Hamlets and elsewhere die because the ambulance does not come to collect them. The elective services are not working. People are still waiting for years to have operations such as hip replacements—ordinary things which hugely improve their quality of life. The emergency services are not working. People are waiting on trolleys, as the hon. Member for Barking (Ms Hodge) illustrated, and then do not get home. Primary care often is not working; there are still grim GP surgeries. Community care certainly is not working. People are often discharged into totally inadequate care. The answer is that the London health service often is not working. Our job must be to try to ensure that it does.

My last point relates to Guy's. The hon. Members for Chislehurst (Mr. Sims) and for Dulwich (Ms Jowell), to whom I pay tribute, are seeking to work with me and with the wider community to persuade the Government that the argument for Guy's to be run down is flawed. We think that we have a case which, on a rational, non-prejudiced, non-partisan basis, if the Government are reasonable and honest, will win the argument.

I know that the debate will follow and that we are about to have three months' consultation, but I will tell the Minister why we believe that we can make a case that he and his colleagues should find appealing. First, things have moved on from Tomlinson. In effect, Tomlinson proposed that it would be possible to rationalise Guy's and St. Thomas's on one site. The trust board was asked by the Secretary of State to consider that. It did not agree, and proposed that both sites were needed. On 10 February, the Secretary of State announced a strategic direction: in effect, the running down of Guy's. Eventually, three months later, we discovered that it was only a proposal, not a decision. The Chessells committee was set up and put a proposal to the trust board in September this year, but that, too, was rejected.

There is now a further modified proposal. The modified proposal that is likely to be put out for consultation—the trust's latest proposal—has already accepted that it is impossible to run everything on one site. It has accepted that we need beds on both and specialist treatment on both. It has accepted that we will need to use Philip Harris house. The only thing that it has not yet accepted as a principle is that we will need a casualty unit on both. The clinicians never said that they wanted only one site. They said only that of course they would prefer one site if everything could be provided on one site. But it cannot be and will not be, so we are now looking at only a two-site option. We believe that for the avoidance of risk and not putting the lives of patients at greater risk, the sustaining of at least the level of care currently provided, and the most clinically and academically coherent provision, which will of course mean some rationalisation and avoidance of duplication across both sites, there is a proposal that can achieve that. Coincidentally, it can achieve it at a lower capital cost than the proposal coming from the trust and at no greater revenue cost. If I were a Minister I would say, "Thank you, and thank goodness for that."

As in the case of Bart's, some 1 million people are saying that there is a need for Guy's—not just local street traders, schoolteachers and children, but Nobel prize winners from around the world, Japanese business people, and leaders of opinion such as the United States academic community are all saying that Guy's is needed. Bishops and actresses are saying that Guy's is needed. Tory, Labour and Liberal Democrat politicians are saying that Guy's is needed. Ministers and former Health Ministers from both sides of the House are saying that Guy's is needed.

If everybody who has looked at the issue and understands it is telling the Government that a hospital such as Guy's is needed, I hope that the new Minister will realise that the wise thing might be to follow the advice and evidence, and not to apply the prejudice which suggests that a blueprint proposing that Guy's should be run down must be applied. I believe that the Minister can do that. He will make himself and the Government hugely popular if he understands that, and today's debate will have been a seminal influence in ensuring that the Government implement health service reforms in London in a way that is much more understanding of the level of still unmet need.

12.33 pm

The Minister for Health (Mr. Gerald Malone)

I thank hon. Members who were kind enough to welcome me to the Dispatch Box for the first time, in an extremely important debate.

The hon. Member for Leyton (Mr. Cohen) was doing rather well until he gave it all away at the end. As my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke) said, the hon. Gentleman called for yet another review, yet more delay. I want to set my remarks in the context of the fact that I do not believe that we can delay further. We must press ahead with the structural changes that are now in the pipeline and going out for consultation. There is no possibility of going back to square one.

If we were to hold such a debate in 2020, some things would have changed. You, Mr. Deputy Speaker, would be an even more august presence than you are today. I do not know where the rest of us would be. I imagine that the hon. Member for Leyton would have his beard restored, and that it could be snowy white. He might refer to the hon. Member for Islington, North (Mr. Corbyn), seated behind him, for advice on that aspect. I am sure that the hon. Member for Leyton will still be calling for yet another review.

I wanted to delay my intervention until the House had a chance to hear the hon. Member for Southwark and Bermondsey (Mr. Hughes). We were not disappointed. I am tempted to hand over the whole service to the bishops and actresses, who have such a detailed and concise view of it and have expressed their opinions.

I met the hon. Member for Southwark and Bermondsey when he was canvassing in the rather unlikely circumstances of the Conservative party conference in Bournemouth. Looking like a lost soul, he was walking up and down the pavement with his "Save Guy's" balloons in front of a "Kill the Bill" demonstration. The hon. Gentleman cut a relatively lonely figure, so I gave him succour and promised to listen to the important points that he made about Guy's, St. Thomas's and the future. I and my colleagues in the Department have considered the arguments with great care.

As the hon. Member for Southwark and Bermondsey said, we are entering a period of consultation. I am determined that it will proceed and be well informed, and that all views will seriously be borne in mind when Ministers consider the matter. I give the hon. Gentleman that guarantee. If he wants to bring his balloons to the Department to press any further points on me, he is more than welcome.

London's health care problems are extremely well known. They have been debated not just since Tomlinson—which made an important contribution—but following the publication of report after report over many years. Government strategy was clearly set out in "Making London Better", published in February 1993. It is easy to agree across the Floor of the House on the motherhood principle—that we want the best health care for all and higher standards of care and, particularly in respect of primary care in London, that substantial improvements need to be made.

At times, however, we must take hard decisions. I will make the point, including to my right hon. and hon. Friends who have contributed to the debate, that, while we are given many views about that which must remain and what is best, everyone also agrees that things must change. The two are logically incompatible. There cannot be change with everything remaining the same. We must face that, and take decisions that will often be difficult and uncomfortable.

Nobody—least of all in government, and certainly not me—approaches London's problems lightly. None of us fails to appreciate that any major programme of change, particularly that involving famous and well-loved and respected institutions, causes anxiety and attracts attention. Equally understandably, the reaction of many people is to shrink from the need for change and not to take difficult decisions. The instinct is to retain the status quo, but that is not an option.

I was interested in remarks about funding and capitation, and I will deal with them in detail later. However, in the context of London in particular, it is clear that the capital's population has reduced significantly over the past three decades, by 1.3 million between 1961 and 1991.

One cannot have such a change in population pattern without it necessitating a change in structure. In addition, there have been many changes in practice. Some hon. Members referred to the fact that beds are the only important criterion. Everyone seems to measure the service by bed numbers, but perhaps such a measure is far too narrow. It is a little like a restaurateur deciding that his restaurant is successful simply by counting the number of seats, and not bothering about the number of satisfied customers.

The truth is that it is not only the population changes that are driving the need for the number of acute beds in London to be questioned. That is happening not merely in Britain but throughout the world. Some of the figures for acute bed reductions in other developed countries are remarkable. For example, Ireland has lost more than 40 per cent. of its hospital beds in recent years, and the same is true in the United States, where 20 per cent. have been lost in the past decade. In any developed economy with a developed health care system, much the same can be seen. There are simple reasons, and many are medically driven.

People are no longer required to remain in hospital for as long after an acute episode. They go to day centres, and hospital-at-home services are being introduced. Intermediate facilities are springing up, which I very much welcome. People move from acute beds to the intermediate service before they are finally discharged. The bed test is simply no longer valid as the most important element in deciding what should happen to health care and whether the reforms that have been put forward and on which we are consulting are right, well informed and likely to be successful.

Several hon. Members mentioned capitation, and asked about the Government's intentions. As hon. Members on both sides of the House know, the capitation formula is intended to ensure fairness. My hon. Friend the Member for Colchester, South and Maldon (Mr. Whittingdale) mentioned that fact, and urged us to consider the best available information when informing our decisions about future funding. I am delighted to be able to respond and to tell him that of course that is what the Government will do.

Anyone who cares to consult this morning's British Medical Journal will discover that the York report is published there. The equations are there, as well as the logic behind York. That formula will be used to inform Government in decisions taken about capitation in future. Of course it will be—it is sensible. Guidance is being published and circulated to the national health service to that effect.

That reinforces the Government's policy that money must be distributed fairly and transparently to the health service. Allocations will continue to reflect local population characteristics and health needs. Where change is seen to be necessary it will be made certain that any transition is smooth and that it is put in place without dislocation, which is extremely important.

Mr. Soley

Many hon. Members remember that one of the failings of the Tomlinson report was that he was told to consider the situation in London, and did not take into account the fact that many of our hospitals draw in patients from areas outside London. The Minister seems now to be saying that we will take that into account. The contradiction in the Government's position is that they are not clear whether they are considering the hospitals' entire catchment area, in which case the Minister is throwing out many of the figures in Tomlinson, or whether they will stick to Tomlinson, in which case he must ignore the outer London influence.

Mr. Malone

The hon. Gentleman misunderstands the position. When taking decisions and distributing cash throughout the country at regional level, the Government look at the formula that influences those decisions. The system also has many other drivers. Thereafter, when the regions distribute at a more local level, they take the needs very much into account and inform themselves on that basis. It is a complex process, and one that cannot simply be driven by a straightforward equation. One cannot merely press the button and get out an answer. It is an informed, well-established process, and it fundamentally underpins the fairness of the distribution of [...]esources across the country. A number of my hon. Friends have rightly mentioned that matter.

Ms Glenda Jackson (Hampstead and Highgate)

I am nterested in the Minister's statement that there will be a fair distribution of health service resources. In the light of the story in today's The Guardian that the Secretary of State for Health has admitted that she does not know how much GP fundholding is costing the health service budget, how can the Government proceed on this basis?

Mr. Malone

The hon. Lady gives a partial account of an inaccurate story, which I read with some interest this morning. Of course we seek to identify the cost of providing services, and I shall return to that later, but I now wish to deal with the point about management costs that was raised earlier.

Mr. Jenkin

Will my hon. Friend give way?

Mr. Malone

I must make some progress, as I do not want to occupy too much of the House's time. I wish to deal specifically with a number of the points that have been made.

New money is being spent in London, and much is happening. The development of new day centres is important, because it changes the pattern of need, moves us away from the idea that care must always be in the hospital, and underpins the fact that there should be no fiat from the Department or from me as a Minister.

I was flattered to gain the feeling from the House that it would be better to get rid of the NHS so that hon. Members could ask me what to do. We must change the perception of where we are in the health service, and understand that reforms are driven by patients through primary care. Through the contracting and purchaser-provider relationship, patients now determine the pattern of care.

Mr. Jeremy Corbyn (Islington, North)

Will the Minister give way?

Mr. Malone

If the hon. Gentleman does not mind, I shall not, as I wish to deal with a number of hon. Members' points.

Let me turn to the important question of consultation. In the next few weeks and months, there will be public consultation on changes in north-east London, and in the north central sector early in the new year. I expect to hear proposals from west London as soon as possible.

My right hon. Friend the Member for Chelsea (Mr. Scott) mentioned the Royal Brompton hospital. I listened to what he said and—although this may not reassure him, it will at least show the attention that we have paid to these matters—I have a visit scheduled to that hospital. I shall consider the proposals to which he referred, which will be borne very much in mind.

The south-east London commissioning agency expects to consult on its proposal for change from the middle of November. As the hon. Member for Southwark and Bermondsey said, we are proceeding on the Guy's/St Thomas's proposal. I hope that consultation will get under way quickly and that, once it is concluded, we shall be able to achieve a stable result as quickly as we possibly can.

My right hon. Friend the Member for City of London and Westminster, South mentioned Bart's. The Royal London hospital trust has embarked on an important plan, which we believe will improve hospital services for all people in that part of London. I visited Whitechapel hospital yesterday, where I saw what is being done. I say to hon. Members who have mentioned its future that £8 million of refurbishment expenses were authorised yesterday. The hospital will now redevelop four wards, improve the accident and emergency unit and put in place an emergency ward next to the casualty department. Those are all extremely important improvements.

We recognise that change is difficult, but we need strong and determined leadership. As my right hon. Friend the Member for City of London and Westminster, South clearly recognised, we need to proceed: we do not need delay, uncertainty and continuing paralysis. When I talked to the clinicians yesterday—not only those from the Whitechapel hospital but from Bart's—the message that came through loud and clear was that no one should stand in the way of change, some of which they may not like but which they regard as necessary if services are to be put on a stable footing and if the teams of clinical excellence are to be kept together.

Mr. Corbyn

While the Minister is talking about nurse-managed beds, does he realise that, in many parts of inner London, people leaving acute beds, who are elderly, often have no one at home to support them, and only very limited social services support? Is he prepared to listen to proposals to convert the Royal Northern hospital in the Holloway road into a nurse-managed bed centre for people leaving acute wards, instead of selling the building?

Mr. Malone

I am glad that the hon. Gentleman has asked me to listen, and not to decide as others have done. I do not wish to palm him off with the motherhood answer—"Of course we will listen". We do listen, but we do more. I like to inform myself of precisely what is happening. As I go around London, I ask precisely what is being done about the community care packages that are being put together—especially the primary care packages, with which I shall deal shortly and which cover hospital-at-home services and ensure that the boundaries that used to exist between primary carers of all types are being broken down.

I concede that the hon. Gentleman has a point, but it is being dealt with. He will be aware that substantial improvements are being made. I now revert to the motherhood answer, and can tell him that I will examine seriously any suggestion that he cares to make.

I deal again with the point raised by my right hon. Friend the Member for City of London and Westminster, South. I should like to read a letter that we received from a professor of medicine at Bart's, which states: We are in no doubt that making no change in the current environment would result in severe damage to the working of all three institutions. We are confident that the proposed plan, if approved after consultation, and if appropriately funded, for the development of a modern hospital on a single site at Whitechapel over the coming years, will provide all the stability and facilities required to look after our local population and provide outstanding specialist services for others from far away. That letter highlights the fact that there are opinions among the professionals who work at the institutions involved which are much at variance with what is often perceived to be the public view.

Mr. Brooke

The hazard in quoting individual documents and individual observations is ascertaining whether they are genuinely representative of the institutions from which they come. Some people might say that the particular letter cited by my hon. Friend is not representative of the institution from which it comes.

Mr. Malone

I concede that there are many opinions, and that they must all be taken into account. My point is that some people believe that restructuring is necessary. I hope that we can draw up a co-ordinated plan in order to ensure certainty and end any further delay.

My right hon. Friend asked me specifically about the services that would be moved, and whether there would be sufficient investment to provide replacement facilities. Such matters are informed not only by the decisions taken by the Department but by other matters. It is, for example, rather premature at this stage in the public expenditure survey to give details of any decisions. I know that my right hon. Friend will understand that well enough.

I give this undertaking to the House: the Government are committed to making resources available to fund rationalisation wherever necessary. It was brought home to me vigorously yesterday that it is important to convince clinicians who were being asked to move that the new facilities would be on all fours with the facilities that they were leaving. That would certainly be an objective. For the reasons that I have stated, I cannot give my right hon. Friend an undertaking as such on that point, but I hope that he understands that that is the objective, and that our deliberations are cast in that way and in the light of all that.

We are rightly proud of the history of much of London's medicine, not least of all science and research, and I now turn to that point. Unless we adapt to the very different reality that we face now, there is a great danger of condemning London's research to the second division instead of it being in the premier league, where more people suggest it should belong. The risk of inaction now is that London's teaching and research institutions would lose their range and flexibility and would become marginalised. Doing nothing in that sense is not an option.

Research thrives where expertise is concentrated—the hon. Member for Southwark and Bermondsey made that point. It thrives where different disciplines can form a critical mass of teaching, research and clinical practice, where biochemists can work side by side with cancer specialists. If we allow London's research to remain fragmented, the slide that is now perceptible will simply continue. Planned changes will address the problem.

All the undergraduate medical schools proposed for merger are now committed to merge, and are developing their plans. Progress in linking postgraduate medical schools to multi-faculty colleges has been faster even than we had hoped. Funding is available to do all this. The Higher Education Funding Council for England has announced a £50 million fund for capital projects between 1995 and 1997, and has invited bids from merger groups. The Department of Health has supported with funds some of the developments that have been triggered by the service changes, and I welcome all that.

It is important to make those who write, along with the bishops and actresses from abroad who were, perhaps, better acquainted with all the institutions some decades ago, understand that, if the institutions are to survive, playing in the premier league, change is now essential, and we must now move on.

I turn now to some of the points raised in the debate. My right hon. Friend the Member for Chelsea not only welcomed the success of the Brompton and its record of excellence in delivering specialist clinical services and supporting high-quality medical research, but talked much about the pattern of provision that he wanted to see in the area that he represents. Of course we shall listen to all he has said, and I can promise him this.

My right hon. Friend asked, as many other hon. Members have done, that uncertainty be kept to a minimum. I can promise him that, once consultation processes have been gone through and looked at thoroughly, within the context of that thoroughness Ministers will, of course, act promptly to ensure that there is the least possible delay. My right hon. Friend asked me to reassure him on that point, and I am extremely happy to give him that reassurance.

The hon. Member for Leyton made a number of points, referring specifically to improvements in the family doctor and community health services throughout the capital, which he said were not there. I tell him that these matters are proceeding.

Primary care is one of the first things that I looked at on becoming a Minister late in July. I take the improvement of primary health care in London extremely seriously. I was amazed to discover the state it was in when I came to office, and I was disappointed that a number of obstacles were still clearly in the way, driven by the health service before it was reformed. Only now, through the actions of clinicians, has the health service been able to make improvements. Anybody going round London now, who looks at the surgeries of the future rather than having to examine those of the past, will know precisely what I mean.

Ms Tessa Jowell (Dulwich)

I am sure that the House shares the Minister's view that improvements in primary care are urgently needed and are a precondition for any subsequent changes. Does he accept, however, the point already made, that improvements in the quality of primary care do not necessarily lead to a reduction in the demand for secondary care? Indeed, the evidence points in quite the opposite direction. Does he accept that point?

Mr. Malone

No, I do not accept that point in the way that the hon. Lady puts it because, in the primary sector, quite a lot of care is now provided which used to be provided in the acute sector, in the ways that I have already outlined. I do not think that there is any logical connection at all in suggesting that improving primary care will either automatically increase in a dramatic way the calls on the acute sector.

Much of what is being done in the reshaping of primary care is taking care away from the acute sector and into the community where it properly belongs, may I say, and in an excellent way. I have seen a number of examples of how the funding made through the Government, and particularly through local health services, in primary health care in London has worked.

As I was saying, I was in the constituency recently of the hon. Member for Southwark and Bermondsey in the rather curious location of a surgery by the name of The Dun Cow. It was an old pub. There was a happy photograph on the wall of the hon. Gentleman opening the surgery—at that stage not with balloons in his hand, but with a pint of beer. I did not know that he tippled to that extent. I shall have to have a word with the chief medical officer about that.

Ms Dawn Primarolo (Bristol, South)

It is in moderation only.

Mr. Malone

I may need to take the advice of the hon. Lady on that. But there it was—a £400,000 development. I was keen to look not simply at the new premises, but at the old as well.

Frankly, such premises are still all too common in London. When I look at new premises, I always insist on asking the question, "Where have you come from?" Often, they have come from facilities which are outdated, where proper medical practice cannot take place. It is important that many of the facilities which can now be brought to bear in primary care, even through pressure of size of accommodation, cannot be sorted out. How does one, in what is often a single room with partitions, bring in either a physiotherapist, a practice nurse and all of the things that primary care packages, especially when they are organised by GP fundholders, are able to provide?

I have also been extremely impressed by a number of other developments. The point that I wish to make bears directly on the issue of accident and emergency departments. I do not want to go through a list of yesses, noes or perhapses and all the representations that have been made in the debate, but there are examples in London of accident and emergency departments being successfully replaced by minor injuries units.

The first one that I visited was at the St. Charles hospital. It is a first-class unit run by a combination of nurses and general practitioners in alliance with consultants from the local general hospital. It was asked earlier whether such units were effective or not. Where it is agreed that protocols can be sorted out between the nurse who runs the unit and the local consultants, they are enormously successful. They can deliver health care in an excellent way. The unit at St. Charles was putting through 15,000 patients a year.

I hope that all our debates on the future of accident and emergency units will be informed by the fact that perhaps, there too, medicine has moved on; needs have changed. It is rather important to recognise that, and to look not only at the old institutions.

The hon. Member for Feltham and Heston (Mr. Keen) made a specific point about a plan in a local hospital in his constituency. I shall certainly consider all that when it eventually comes to Ministers. I cannot give him any undertaking to do more than that, but as that is the undertaking he sought, I hope that, when he hears of it, he will take it in the good will in which it is given.

The hon. Gentleman also raised an important point, on which the House reflected, about trust board membership. I am rather looking forward to the opportunity that the Opposition have given us to debate the point at some length next Tuesday, because up and down the land many people—professionals—are doing what is almost voluntary work for the health service. It is conducted in a first-class way, and I believe that they serve the service well.

I do not share the view of Opposition Members, who think that that is not a proper way to run affairs. I think that it is an excellent way in which to run those trusts. They make a marvellous contribution. The hon. Member for Feltham and Heston does not do a service to anybody who does that work to decry them constantly and say that their service is not worth very much. The hon. Member for Hornsey and Wood Green (Mrs. Roche) also made that point. She referred to the management costs of the NHS.

It is remarkable that no Opposition Member referred to the fact that yesterday we published the management statistics in the health service. They show that management comprises only 2.6 per cent. of the service. I can never understand how Opposition can expect a modern health service, with a budget of £32 billion, to be run properly and to deliver health care in a complex way unless it is properly managed. I look forward to the debate next Tuesday, when we will go into those matters in more detail than we should today.

My hon. Friend the Member for Romford (Sir M. Neubert) raised a specific constituency point. He is aware that the regional health authority has approved plans to close the Oldchurch accident and emergency unit and to centralise at Harold Wood hospital. As my hon. Friend will be aware, the Secretary of State will take the final decision shortly. We will listen to what has been said and consider what has been written by hon. Members, especially in this debate, and a decision will be informed by that.

In response to the hon. Member for Barking (Ms Hodge), I reiterate the importance of minor injuries units. She referred to the fact that it may not be possible to replace A and E units satisfactorily with minor injuries units. With regard to my earlier point, where protocols are sorted out properly, it is feasible to do that.

I do not wish to detain the House too long, but I want to deal with several points before I allow other hon. Members to speak. In particular, I want to deal with a point raised by the right hon. Member for Bethnal Green and Stepney (Mr. Shore).

We do take the position of the London ambulance service extremely seriously. However, when it is being criticised, we should recall that it is the one ambulance service in the country which does not have trust status and is not managed in the same way as ambulance trusts. I firmly believe that one of the reasons for that is that the work practices within the service are not conducive to delivering the best service.

I want now to consider the terms of reference of the inquiry set up by my right hon. Friend the Secretary of State. It will be a rapid inquiry, so that we can produce quantifiable benefits quickly. The inquiry will do several things. It will consider working practices, including staff deployment, rostering, crewing policies and timing of annual leave.

The specific problems identified in the tragic case which has attracted so much recent publicity must be addressed. The inquiry will consider systems and the use of resources. The right hon. Member for Bethnal Green and Stepney suggested that it should consider management, and it will do that. One of the inquiry's criteria is to examine management and staff training.

It is very easy for politicians—on occasion, I am as guilty of this as anyone—to use the buzz words and call for a full-scale public inquiry—I accept that the right hon. Member for Bethnal Green and Stepney has not done that in this context, but others have—but we must make some rapid progress to find a quick way to solve the problems. We agree with the right hon. Gentleman that what is happening is not satisfactory and must be changed.

The statistics of the London ambulance service show that the cost per patient transported is higher than nearly any other ambulance service in the country. There could be indicative reasons why that should be the case only in London, but on the outskirts of London the costs are less, and decently managed services can produce far better response times. The purpose of promoting the inquiry is to raise the London ambulance service at least to average standard, and I hope beyond, in hitting targets.

We recognise also the special problem of mental health services in the capital. The matter attracts intense media attention. In 1991, we introduced the mental illness specific grant to encourage local authorities to increase social care for people with severe mental illness. The mental illness specific grant was increased to £36 million for 1994–95, supporting expenditure of £50 million and funding 800 projects. This year, we have made an extra £10 million available to be spent on community mental health services in areas of greatest need in London.

I take this opportunity to underpin the principles of care in the community. Anybody who visits a Victorian institution in which people were almost locked up and the keys thrown away, will understand that a Government who had not embarked on the humane policy of introducing care in the community for the mentally ill would have been seriously at fault.

Everywhere I go around the country I see two things happensing in common: better services, but concern from the public. Concerns must and will be addressed, particularly in respect of patients who are a special risk, and they will be taken seriously by the Government whenever problems arise. I hope that the basic tenet of the policy, which is broadly accepted by both sides, is not undermined by specific instances, no matter how much publicity they might attract.

I shall say a word or two about the future of the London Implementation Group. I expect the LIG to transfer its functions during 1994 and the beginning of 1995 to other parts of the NHS executive, including the relevant regional offices. I shall say a special word about the primary care support force, which I launched two to three weeks ago. Its work will continue specifically, because Ministers have identified the improvement of primary care as a specific need in the city.

What will the future of London be? If it were to be left to yet more commissions, yet more full-scale inquiries, "let's wait" and "let's see", the future would be the spiral of decline that Tomlinson predicted. We must act. The Government must support the plans that need to be put in place to bring about the reconstructions in the broadest sense that we are able to. That support will be available.

I inform hon. Members who take an understandably keen and direct interest in such matters that we are keen to proceed so that we can reach the conclusion of the problem. But to suggest that all we may do is sit back, have further inquiries and further delay, would be the worst possible thing for health care in London.

I am pleased to make this ministerial debut on such a matter of great importance. I assure the House that Ministers will continue seriously to consider what is happening in London health care and will ensure that the improvements that we are beginning to see with the projects that are coming on stream around the capital are given every impetus from the Government. I look forward to performing that duty in the coming months and years in the interests not only of those who practise in the service and who do such a great job but of those who are probably mentioned least of all, and that is the patients, who need to benefit from the changes.

1.13 pm

Ms Dawn Primarolo (Bristol, South)

I congratulate my hon. Friend the Member for Leyton (Mr. Cohen) on initiating today's debate two years after publication of the Tomlinson report. I also congratulate other hon. Members who have participated in the debate. I welcome the Minister to his new post. I assure him that it will be exciting, stimulating and challenging. We intend to continue to place before him the difficulties that the NHS is experiencing. Hon. Members raise with the Minister constituency health care issues and problems because he is responsible for the national health service.

As my hon. Friend the Member for Barking (Ms Hodge) said, detective work in the NHS is necessary to try to find out who is responsible for taking decisions. That leaves with us no option but to bring the matter straight to the Minister's attention. The Government's new approach to so-called accountability in the health service—the "light touch" as I think they like to call it—consists of the Government taking the credit when something goes right but ensuring that they do not take responsibility when it goes wrong.

Two very powerful themes have continued to emerge in all the speeches today. The first is the Government reforms and the impact of those reforms and of the internal market not just on London's health care but on a wider region. I, too, look forward to Tuesday's debate when we shall be able to broaden the issues covered. We shall also consider the Tomlinson report and its proposals, the reason and justification for what is happening in London.

I say to Conservative Members that it does not matter what we say or do: they will not allow the facts to speak loudly or change their commitment to dogma and faith in a market system that is destroying our health service. Many myths on health care—and particularly funding—continue to be pushed by the Government. I should like to pick up on the one on funding given that the Minister paid some attention to it himself.

The Government have always advanced the argument that London receives a disproportionate amount of funding for the NHS. They said that the population of London was not large enough to justify the resources that it was given. That is not the case. The Department of Health admits that that is not the case—or certainly that it does not know whether it is the case.

When we tabled questions to the Department asking specifically for the share of resources allocated to London as compared with the rest of the country, the answer was that It is not possible to apportion … spending geographically."— [Official Report, 23 June 1994; Vol. 245, c. 300.] If it is impossible to apportion spending geographically in working out where money is going, what is all this rubbish about London receiving too much money? Where do the facts come from for that assertion? Did every Conservative Member who advanced that myth contact every district health authority in London and ask it how much it receives? Did they then compare that with the percentage of national spending on health? I do not think that they can have done that. Had they done so, they would have found that London has approximately 15 per cent. of the population of this country and that it receives about 15.4 per cent. of the total allocation, so where is this rubbish about London receiving too much money coming from? It simply is not the case.

Mr. Jenkin

Will the hon. Lady give way?

Ms Primarolo

The hon. Gentleman has intervened a number of times. It is a long debate and I should like to make some progress.

The Government claim that they want a non-partisan debate on health and that they want to consider the serious issues. When that is offered to them, however, they continue to ridicule. They should make up their minds whether they want a full ideological battle or whether they are prepared to discuss what is best for London and what is not.

Mr. Jenkin

rose—

Ms Primarolo

I have told the hon. Gentleman that I do not intend to give way at this stage. I hope that he has now understood that.

The issue of who is responsible is important. The Minister is clearly surprised about the state of the health service, in London or anywhere else, and that is stunning. The Government have had 15 years in power and three years of reforms to make the health service better but they have only just noticed that it is not working. That is a measure of their competence and understanding of what is going on.

Let us look at what Tomlinson proposed. Some of the data that he was given were subsequently shown to be inaccurate. He was asked not to assess the health needs of London and to find out what it needed but to assume the working of an internal market. He was to assume that there was too much money in London, which is incorrect, and that there were too many beds, which is also incorrect.

Tomlinson's mistake was to look only at acute beds and not at medical and acute beds, which in every other part of the country are put together. He said that 2,000 London beds should be closed but since the report was published, 2,500 have been closed. Why is there so much talk about the need to press ahead with a plan whose aims have already been achieved?

We are told that we need rationalisation of specialties, and of course it makes sense to have the best resources in the best locations. But why interfere with that at Guy's and at Bart's? Why destroy those services instead of allowing the local community to make known what it needs? The Government told us that they wanted to develop primary care. We agree that we need such development, but so far no resources have found their way into the delivery of primary care. Many great schemes have been started but there has been no measurable improvement. There are fewer GPs in London than there were three years ago. That shows the extent of the investment in primary care in that sector—let alone in the other health professions.

A Conservative Member who is not a London Member said that he wanted to speak for his area. My constituency is not in one of the four London regions but when fighting for resources for it I am not prepared to engage in a divide-and-rule policy by saying that London should be cheated of its resources so that other areas can have them. I know from my experience in Bristol and from that of my colleagues in Manchester, Birmingham, Liverpool and Edinburgh that exactly the same case is now being used to cut services in those areas.

It is about time that the Government looked at the facts and reassessed what is going on. We have asked for that a number of times, and countless reports with which we have not necessarily agreed have requested it, but the Government are not prepared to budge. They will not listen to Londoners or academics and they will not look at the facts and consider the views of the Opposition. In a desperate effort to achieve some sort of progress to protect London's health we have offered another way of finding common ground.

If Conservative Members do not like the idea of another review of available information with a moratorium while it is being held, why do they not at least listen to the evidence that is around? Two years ago the Government published their document "Making London Better" but the policy contained in that has become a sick joke. Access for patients and the quality of care have disappeared in sloganising about the internal market and the jargon of GP fundholding. That has happened because of the Government's constant need to think about privatisation and competition instead of collective provision.

On the question of the London ambulance service, perhaps the Minister would consider reassessing his response to a written question from my hon. Friend the Member for Newham, South (Mr. Spearing) on 17 October. My hon. Friend received details from the Department of the number of times that emergency responses exceeded either 34 minutes or 45 minutes. For example, in London on 19 June 1994, 330 emergency calls took more than 34 minutes and 131 more than 45 minutes. The Minister would not agree to investigate the reasons for that or give categories of reasons why that happened. When he undertakes the wider consideration of the LAS, will he ensure that those issues are also dealt with?

Mr. Spearing

The figures to which my hon. Friend referred were for the week ending on 19 June. Nevertheless, is the Minister aware that when ambulance services were run by borough councils and the GLC, local councillors could find out the reasons for any delay? It is not right that the Government should deny that information to Members of Parliament.

Just for good measure, is the Minister aware that last Monday a call was made at the Finchley Tesco— appropriately enough, about a man with a heart attack—and the ambulance arrived half an hour after the call? However, a fire engine that had been called in desperation because it had oxygen on board arrived first. The fire service is run by a London borough council; the ambulance service is run by the Secretary of State. She has had five years' warning of what has been happening.

Ms Primarolo

I am grateful for my hon. Friend's correction. I am sure that the Minister will study his points in Hansard and consider whether they can be dealt with in the inquiry.

The Secretary of State has shown scant regard for public opinion. Even the London Implementation Group, the body that she set up 18 months ago to enforce her changes, has not held one meeting in public. It meets in secret to decide the future of London's services. It has 30 staff and an annual budget of £2 million. It is chaired by a former Conservative Member—what a surprise. Why do the Government continue to invest money in quangos in an attempt to justify the lack of strategic planning and accountability in London? Why do not they invest in a regional health authority that can strategically plan London's health services?

Mr. Malone

I would not usually intervene on a minor point, but it has been mentioned twice today. I was unaware that the chairman of the London Implementation Group is a former Conservative Member. I am sure that the hon. Lady wants to set the record straight on that.

Ms Primarolo

Is Sir Tim Chessels not a former Conservative Member? [HON. MEMBERS: "No."] I stand corrected—

Mr. Jenkin

The hon. Lady should get her facts right.

Ms Primarolo

When it is pointed out to me that I am wrong, at least I am prepared to note it. I am grateful to the Minister for correcting me. However, I am sure that he would not deny that the chairman is a Tory. We must not go further into this matter; I should not have started it.

The people's lack of faith in the Department of Health is clear, as we hear at every public engagement in London. That is not surprising, given that "Making London Better" has become a policy under which operating theatres close so that the curtain on the theatre of the absurd can rise.

How absurd to waste the £140 million that was spent on Philip Harris house at Guy's just so that the Government can get their own way. How absurd that the Chelsea and Westminster hospital—a £200 million showpiece hospital—has beds empty while waiting lists rise. It then announces that it plans to open a new ward but—what a surprise—it is for private patients only. How absurd that, if one lives in Barking, one will be seen within weeks at King George's hospital, but in Redbridge, if one lives locally in Barkingside, one must wait 18 months. How absurd that there are fewer GPs in London, but a 57 per cent. increase in the number of managers running the system. How absurd that the Royal Brompton hospital, the national heart and lung hospital, can survive financially in the internal market only if it goes into a £20 million partnership which involves a private company building a 28-bed patient unit and running the NHS catering, domestic and laboratory services.

How absurd that Bart's should be scheduled for closure on a financial package that is so appalling that the current figures demonstrate that there is no financial gain to the taxpayer for 30 years at least. Then the Government have the cheek to tell us about effective use of resources, about making sure that patients get what they need. How absurd that a Health Minister, in justifying the closure of Bart's casualty, can say that the 10,000 extra attendances that the accident and emergency unit at University College hospital will have to deal with will be perfectly all right and that they will be able to be absorbed by the additional and existing facilities that UCH already has. That hospital is struggling to restructure itself under a lack of finance and constant criticism from the Government.

Today's debate has been about trying to persuade the Government that their facts are wrong. If they do not agree with all our interprpetations, we ask them to look at the reports and responses—indeed, we ask them to listen to members of the public and what they have to say about the health services that they want to see in London.

Alan Langlands recently told The Guardian: I find it very difficult to judge what the population of London thinks about the changes.

What utter nonsense. Where is he living—on the moon? How could he possibly not know? He has only to read the Evening Standard, which is not known to be a socialist rag—as yet anyway—to see the fantastic campaign that it has been running. He has only to listen to the three Conservative Members of Parliament who speak with one voice against the proposals for their local hospital in Edgware. He would have only to go to a few of the community health councils in London to find out what was going on, or perhaps attend some of the local authority meetings at which the difficulties that are being experienced because of the rundown of the health service and the provision of continuing care are being discussed. He has only to ask what the people think in the area of North Middlesex hospital. When he finds out that an employee acting as chief executive is paid £12,500 a month for a four-day week, he will know what people in London think about their health service.

Action must be taken now. The Minister should take this opportunity to announce an immediate end to hospital and bed closure programmes. He should publish in full the York report.

Mr. Malone

It has appeared.

Ms Primarolo

It is not published in full.

The Minister should allow a proper debate about the funding of the health service—about how much we are prepared to pay and how the funding formulae should be calculated. We must ensure that health funding is apportioned according to need.

All that must be done if there is to be real hope of long-term improvement. Aspirations must be tempered by analysis, research and strategic thinking. The Conservatives' ideological commitment to the internal market and to setting one health authority against another and one hospital against another prevents sensible planning and stops patients receiving the excellent services that they expect and deserve. Unless the issue is resolved, the people of London and the Government will face not only a winter of discontent but a winter of desperate disappointment.

Yet again we ask the Government to establish a strategic planning authority for London—elected, accountable and responsible for delivering the capital's health service—and to call a halt to further bed closures. We make it clear in respect of Bart's, Guy's or any other hospital that when we are elected as the Government, we will have the guts to review the present Government's decisions on the basis of information and research, not prejudice.

Mr. Malone

Before the hon. Lady sits down, perhaps I may point out that the York report was published in full by the university. The hon. Lady can have the abstract that I obtained from the British Medical Journal this morning. There is no question of the report being suppressed. It was not for the Government to publish that report, which was the work of York university. It has been published in full and is available.

Ms Primarolo

The report was prepared for the Government in considering their funding formula. The Government have had that report a long time. Everyone agreed, when this point was made in the House, that any funding formula must be fair and understandable and must work in terms of supplying a strategic base for the health service. If the Minister is so confident that the new formula can be succinctly explained—although I understand that nobody in the Department of Health can manage to do that—I trust that he will present the shorter version in next Tuesday's debate, so that we may be clear as to what is on offer.

Again we ask the Government to consider the best needs of London's health service based on information and listening to the public, and to plan strategically for the future. We ask the Government to stop putting up Aunt Sallys which are irrelevant to this debate, which confuse and which help the Government to avoid answering the real questions. The people of London want quality care and access to it when they need it, as do people in the rest of the country.

1.37 pm

Mr. David Congdon (Croydon, North-East)

One disappointing feature of the debate has been the failure of Opposition Members to face up to the real difficulties that are confronting London and to the need to rationalise services. Those difficulties have been recognised in more than 20 reports on London's health care published over 100 years. The problems were recognised before the establishment of the NHS in 1948.

Everyone is clear that a key problem is over-concentration of resources in central London, particularly of specialist hospitals. Many people are prepared, however reluctantly, to accept the need for rationalisation, but when it comes to their local hospitals, they can inevitably find 1,001 reasons why they should not be affected. It is easy to support a strategy but much harder to support specific proposals.

The hon. Member for Bristol, South (Ms Primarolo) spoke of establishing a strategic planning authority, as if that would avoid the need to take action now. That is simply a device for avoiding difficult decisions, which the Opposition want to do all the time.

I will not go into all the reasons—outlined in the original 1992 King's Fund report—why change had to occur, but I must emphasise some of the additional pressures in London at this time. We know that the pressures of the funding formulae have led to resources moving away from London and I will certainly welcome a positive response from the Government to the York university research. My experiences in Croydon and the work done by the director of public health there lead me to conclude that the formulae do not give sufficient emphasis or weight to social deprivation factors.

There has been much criticism of the internal market, but critics have failed to recognise that it is leading to patients being treated nearer to where they live, rather than having to come to central London simply because it is the only place where the facilities exist. Also, resources have rightly been transferred from primary to secondary care and everyone seems to support such a change. Many people are being treated for minor ailments in their doctors' surgeries, rather than having to go to hospital.

Another additional pressure is community care and the problems that some authorities, especially those in inner London, seem to be having in avoiding bed blocking. Those social services authorities experiencing difficulties should get on with it and use the transitional funding that they have received from the Department of Health to ensure that they stimulate the private sector in their areas, rather than doing everything that they can to impede change.

On the number of beds in London, much misinformation has been spread around about the situation and about Government policy in that respect. In 1992, the King's Fund report, "London Health Care 2010", used 1989–90 figures to argue that the number of beds should be reduced by 10,000 in Greater London as a whole—I stress that the figures were for Greater London. When Tomlinson reported in October of that year, he concentrated on inner London, which is important because certain recent commentators have forgotten that key fact. Tomlinson was talking about inner London and suggested a loss of between 4,000 and 5,000 beds over a period that could be five years, although he was not precise about the exact time scale.

In 1993, the Government published "Making London Better" and recognised the difficulties involved in bringing about some of the changes. They aimed, therefore, for a much more modest target—a reduction of between 2,000 and 2,500 beds, based on the more up-to-date 1990–91 figures.

We moved away from the original base figures in the King's Fund report and had more modest targets. Many of those targets were due to a revision in the number of patients who would come into inner London because of the implementation of the internal market and the fact that people were being treated closer to home, to the changes in the funding formulae that I mentioned and, perhaps more significantly, to the increased efficiency that hospitals throughout the country have achieved.

Despite what has been said this morning, it is important that all hon. Members realise that London is overbedded in comparison with other parts of the country. The average inner London district health authority uses 19.7 beds per 1,000 episodes of acute care, which compares with 1989–90 figures for the rest of the country of 14 beds per 1,000. I mention that because even if London achieved only the latter figure, which is already being bettered elsewhere because of improved efficiency, it could reduce the number of beds by 2,700. If that factor alone were taken into account, the targets laid down in "Making London Better" would be achieved.

I understand people's concern that, despite all that and all the talk of bed numbers, there does not seem to be a surplus of beds in inner London hospitals. We have heard stories of people left on trolleys in accident and emergency departments. Sometimes that is undoubtedly due to pressure on beds, but it might also be due to bad management of services. That does not mean that the strategy is wrong, but I accept that it means that we must be cautious of the pace of change, and aware of it.

Professor Jarman, who has been quoted at length today, argued that we should look at Greater London as a whole. As a Greater London Member, I have some sympathy with that, but the real problem of overbedding and over-resourcing is in inner London. Croydon has never been overfunded. Whenever a formula has shown that we are underfunded and we have begun to get a bit more money, the formula has changed and we have had money taken away. We must look primarily not at Greater London but inner London.

The hon. Member for Bristol, South quoted Jarman to suggest that we have achieved 2,500 bed reductions since Tomlinson reported. That is not correct. Jarman based his figures on a large drop experienced in the late 1980s, but since Tomlinson reported there has been a very small drop in inner London. Between March 1991 and March 1993, surprisingly, inner London lost only 304 beds. My only criticism is that we do not have more up-to-date information, but that shows, first, that Jarman was not correct and, secondly, that he was talking about Greater London rather than inner London.

I was concerned about the issue of bed numbers, so when the Secretary of State appeared before the Select Committee just before the summer recess I asked about bed numbers in London, and, rightly, to a certain extent, she was mildly critical of the fact that I was focusing on bed numbers, which are not the key factor in the provision of health care. Nevertheless, I argue strongly that the rate of change in bed numbers is important, and therefore we need to look carefully at that.

Many figures have been bandied about on funding health in London, but figures from parliamentary answers and from answers given to the Select Committee show that in inner London spending per head is £603, compared with £415 in outer London. Indeed, outer London is only marginally above the average for England, whereas inner London is 57 per cent. above the average.

I do not subscribe to the theory that it is wrong for London to be better funded than the rest of the country. The issue is achieving the right level of funding for London to take account of its particular needs. The figures that I gave earlier suggest that funding is too high, but we need to look carefully at the funding formulae to see what would happen in the next four or five years if all the effects of the current weighted capitation formula arose, and I am concerned about the pace of change.

The King's Fund was quoted earlier as saying that London is underfunded by £200 million. That was based on a report that it published the day before our last debate on health in London in April. Despite a meeting with the King's Fund and the author of the report, and despite having read its latest report, that figure seems to be an assertion rather than a detailed analysis of the situation in London.

The key to the changes in London was the decision to set up the joint trusts for Guy's and St. Thomas's and other hospitals. My plea to the Minister is that, as much as possible, we should leave the decisions on the exact configuration of sites in central London to those trusts. It is difficult for others to judge what is the right configuration, whether for Guy's and St. Thomas's or Bart's and the Royal London hospital. I should like the trusts to take such decisions.

My second plea is that we proceed with caution when considering figures given for the costs of changing sites. Experience suggests that estimates of the capital cost of providing improvements on one site will probably end up being at least double the original sum and that alleged savings will not materialise or will amount to only half the original estimate. In other words, we should treat such figures with great caution.

On behalf of my constituents, I am delighted to learn of the excellent news to improve and expand our accident and emergency department, but I do not want large sums of money spent on new building in inner London because the problem is not a shortage of buildings but a surplus. I urge caution in grandiose schemes for remodelling or rebuilding. As far as possible, we should maximise the use of facilities in which we have already invested.

Although I believe that we should proceed with caution, we should not lose sight of our strategic plans for London. The King's Fund's latest report stated that we should take stock, but it also urged Ministers not to change direction because we had got it right. I wish that more Opposition Members would recognise that the direction in which we are going is the right one.

1.51 pm

Mr. Brian Sedgemore (Hackney, South and Shoreditch)

I welcome the Minister of State to his new post but I hope that it does not sound churlish if I say that, having heard him speak, it appears that he was offered the wrong job.

I wish to pick up some of the points made by the right hon. Member for City of London and Westminster, South (Mr. Brooke). As a free man, he will be a much better person than he was when he was caged in the Cabinet. I was sad that his remarks were answered irresponsibly by the Minister, but I shall go into more detail on that subject later.

If it is a truism that Britain's future lies in the intelligence of its people, it is none the less one that is well worth heeding, and nowhere can it be more true than in medicine. Intelligence in medicine is at its best when individuals combine in centres of excellence such as Bart's medical college and Bart's hospital. The King's Fund medical audit of Bart's two years ago, which was produced just as the Secretary of State for Health embarked on her mission to break up Bart's, reported that the care of the hospital was such that we should "cherish" the hospital. "Cherish" is a strong word.

In 1993, an astonishing 27 per cent. of the people at Bart's medical college got distinctions in their examinations and, in 1994, the figure rose to an amazing 33 per cent. In the seven years from 1988 to 1994, Bart's came first five times among the nine London medical schools according to the number of students with distinctions in examinations; it came second once and third once. That is excellence. Much of that excellence is due to the heroic work of the dean of the college, Professor Lesley Rees. Along with most other thinking people, I was mortified when she was made warden of the new combined London/Bares medical college.

Further to the important point raised by the right hon. Member for City of London and Westminster, South, excellence does not pop out of a bottle like a genie. It does not come from performance review systems or league tables. At Bart's it has been polished and burnished down the centuries until it has become custom and practice, a matter of pride, and simply the right thing to do. If one shows contempt for such excellence, as the Secretary of State does, one shows contempt for civilisation itself.

I do not believe that the hospital will close, despite the best efforts of Sir Derek Boorman, who is now in charge of the trust. However, having been there three times in the past week, I cannot help saying that at Bart's, there is a kind of grief that speaks to pain and love alike in the hearts of people and personalities who cannot bring themselves to understand how it can be that those who run the political system no longer know the difference between right and wrong.

At about the same time as Rahere was inspirationally founding Bart's in 1123, masons and joiners were grappling with the problems of the hammer-beam roof at Westminster Hall in this building. Of the same age and born of the same spirit, Parliament and Bart's both went on to become wonders of the world. Yet, ironically, it is through Parliament and a merger that has turned into a takeover that the Secretary of State is destroying Bart's. As she does so, any sense that Parliament exists to shut out the bad and to bring in the good disappears.

Bart's faces three tragedies. The first is that the Secretary of State has not listened to the people of London or, indeed, to the right hon. Member for City of London and Westminster, South. For some reason that none of us can understand, she has taken a pride in ignoring the rational and emotional, but brilliant campaign of the patients. On Monday, in the House, it really was difficult to speak to them about some of the despair that they felt.

• "To suffer woes which Hope thinks infinite;
• To forgive wrongs darker than death or night;
• To defy Power, which seems omnipotent;
• To love, and bear; to hope till Hope creates
• From its own wreck the thing it contemplates".

Yes, the words of Shelley say it all. I look the Minister straight in the eye as he tries to snigger. Shutting Bart's is evil.

The second tragedy is that the King's Fund, once a respected independent research institute, allowed itself to be used and abused by the Government. It is now so embarrassed at how wrong it was that it has put two of its greatest critics, Professor Brian Jarman and Professor Lesley Rees, on its management committee. However, Professor Rees tells me that she will never forget and she will never forgive, and I understand that.

The third tragedy is the lack of trust generated by this unwholesome mess—the breakdown of trust between competing predatory hospital chief executives, the breakdown of trust between the medical council at Bart's and Sir Derek Boorman, the chairman of the trust, the breakdown of trust between the clinicians at Bart's and the Secretary of State and the breakdown of trust between local Members of Parliament on the one hand and Sir Derek Boorman and the Secretary of State on the other.

The Minister referred to his visit to the London hospital yesterday. He had the temerity to read out to the House one letter from one clinician. That was a monstrous thing to do, as misleading as it could conceivably be, and I am not surprised that the right hon. Member for City of London and Westminster, South got up to correct him. Perhaps the Minister does not know the facts and if he does not know, perhaps I can help him because the information is in the document in the file. In fact, it is on top of the file behind me.

In September, the chairman of the medical council at Bart's wrote to Sir Derek Boorman, the chairman of the trust, and said that he felt that what was being done now was not what they had agreed and that it would be damaging to medical care at the new merged hospital. He concluded first, that the time scale proposed by the trust board was driven by short-term political imperatives and secondly, that the medical council, which represented many more people than one, would strenuously oppose long-term plans that envisaged the eventual closure of St. Bartholomew's at Smithfield. Why, I wonder, was not the Minister told about that yesterday? Since he told us that he talked to so many people about Bart's, why does not he tell us about it here today?

As I said earlier, I have been to Bart's three times in the past seven days and about 100 times in the past two years. In the past seven days, I must have spoken to 30 doctors. None of them is giving the information that the Minister, using one letter, gave to this House. Do we want to give the House accurate information? Does the House deserve the truth, or is the Minister prepared to let down himself, his Government, the nation and Parliament?

Mr. Malone

What a lot of nonsense.

Mr. Sedgemore

The Minister says, "What a lot of nonsense," from a sedentary position. Is he telling me that what I say is not true? Is he really claiming that on a visit to the Royal London hospital yesterday he found out more about the views of every leading doctor, nurse and patient at St. Bartholomew's hospital? If so, that would be nonsense.

Mr. Malone

I am rather surprised that the hon. Gentleman refuses to recognise that there is another view and I think that it is perfectly proper to point it out. I did not for a second suggest that it was the only view. Clearly, it is not. The hon. Gentleman is a mite sensitive about any criticism of what he seems to think is an inevitable position with which everybody agrees. It is not.

Mr. Sedgemore

I do not know whether it is a mite sensitive of me. I am trying to represent the views of a million Londoners, the views of the overwhelming majority of clinicians, consultants, doctors, nurses and patients at St. Bartholomew's hospital. I am trying to put an accurate case to the House and, in fact, not to mislead the House, as the Minister was, on the position of doctors at St. Bartholomew's hospital. The position is not as he said it was from the Dispatch Box.

Perhaps I may go into more detail, since I know rather a lot more about the issue than the Minister. On 19 August, Sir Derek Boorman wrote to The Times and claimed that the cost of transferring services from Bart's to the Royal London was £113 million, made up from £25 million for renovation and £88 million for new building. That was not true. The correct figure, given in the Minister's brief yesterday, as he well knows, was £200 million. In fact, to be precise, in the statistical table that I have here, the figure is £202 million.

How can the chairman of a hospital trust write to The Times and get the figure so wrong? For a start, Sir Derek forgot the existence of the medical college. For someone who does not know much about medicine, it is an understandable mistake, I suppose, but it is not quite the sort of mistake that one expects from the chairman of a hospital trust. I suspect that when Labour comes to power in a few years' time, it will be "hail, glad, confident morn" never again Sir Derek.

In October 1992, we were told that Bart's would have an overspend of £12 million and that it would worsen with time. Bart's said that the figures were wrong, but Tomlinson repeated them—so did Ministers from the Dispatch Box. Again, if the Minister does not want to listen to me, I hope that he heard the point made by the right hon. Member for City of London and Westminster, South.

In the past two years, under the excellent work of the professor of medicine at Bart's, Professor Mike Besser, who was chief executive during that period, Bart's paid off all the outstanding debt and the accumulated deficit of £2.45 million. It repaid all the outstanding loans to the trustees. It put £1 million into the contingency fund. This year, it reported an operating surplus and it has brought the capital account into balance. In other words, Bart's did everything that Ministers asked of it; working—

Mr. Malone

rose—

Mr. Sedgemore

May I finish this point? Working in the internal market, Bart's produced a surplus, got rid of its debts and showed that it was financially viable. What has happened to it now?

Mr. Malone

I assume that the hon. Gentleman is referring to the report of the accounts up until 1994. May I remind him that they apply not just to Bart's but to Bart's and the Homerton? In addition, the accounts include a special payment of £4 million in that year from the special trustees. What the hon. Gentleman has said does not fully represent the position as I understand it from the Besser letter.

Mr. Sedgemore

The Minister must look at the figures. The money from the special trustees has been paid back. Indeed, most of it was never drawn. The Minister will discover that if he checks the figures. I have carried out a detailed study of the matter and I beg the Minister to try to find out what is going on.

I am delighted that the Minister mentioned the Homerton, for two reasons. First, the future should lie in Bart's working closely with the Homerton and not in some kind of predatory relationship between the two. Secondly, we know that what are now called "episode costs" or patient costs are extremely high at the Homerton. The Homerton would benefit from a broader throughput, working in conjunction with Bart's, which would bring the average costs down. The Minister must go back and do his basic homework.

Professor Besser was the chief executive and he ran, along with the patients, a brilliant campaign against the closure of Bart's. He has just been overwhelmingly elected vice-president of the Royal College of Physicians. I am told that his vote represents a recognition of his clinical excellence and an overwhelming condemnation by all the physicians in the country of the actions of the Secretary of State.

I have a petition which has only one signature. It is not a big petition and one may say it is not much of a campaign. It says: We, the undersigned, support St Bartholomew's hospital as patients and friends. Bart's has provided essential services and must continue in its great work. There is just one signature, from one great man. It is the signature of John Smith.

After John Smith died at Bart's, in an act of extraordinary spite, the chairman of the trust, who had decided that there would be provision on the site for the next 13 years, on instructions from civil servants at the Department of Health, reduced that to five or six years in an attempt to prevent a Labour Government from keeping the hospital open. That was a despicable act if ever there was one.

However, that cannot work. First, the hospital cannot be shut within five or six years. Secondly, earlier this week Professor Lesley Rees met my right hon. Friend the leader of the Labour party and they had what might be described as useful and constructive discussions. Finally, my hon. Friend the Member for Bristol, South (Ms Primarolo), whom I regard as the closest thing one can get to a saint in this world, and who replied to the debate today, gave an assurance that when Labour comes to power in three years' time, the decision to close Bart's will be reviewed. At least I leave the House today with some hope; indeed, with considerable hope.

2.7 pm

Mr. Piers Merchant (Beckenham)

I congratulate the hon. Member for Leyton (Mr. Cohen) on instigating this debate today, and on his luck. Had I been so lucky, I might have chosen a similar topic although not in exactly the terms of the hon. Gentleman's motion. The hon. Gentleman was rather premature at the beginning, when he said that he had "won" the debate. I do not think he meant it quite like that. I am not sure whether he had won it then, or whether he has won it now.

I listened carefully and with great interest to most of the contributions. They ranged very widely from listing the major London-wide issues, of which there are many, to equally relevant individual constituency cases which I am sure we have all come across. It was right that the debate should range that widely.

I fear that there has also been a good deal of political point scoring. That is a great shame because no Conservative Member would deny that there are deficiencies, difficulties and problems which should be sorted out. However, it does not help the quality of debate inside or the wider debate across London to indulge in hyperbole because that discredits the people who follow that course.

To suggest that the whole of the health service in London is not working or has collapsed is a gross distortion of the truth. Indeed, it demeans all those in the health service—doctors, nurses, clinicians and managers—who are working hard with the positive aim of improving health care in the capital. Also, that claim cannot be borne out by the hundreds of thousands of people in London who receive extremely good health care and who show their appreciation later. Like many of my colleagues in London, I receive many letters from people saying that they are delighted with their treatment. To suggest that all is doom and gloom is a grave misjudgment.

The wider debate on London health care has been dominated too much by the understandably emotive issues of large and prestigious central London hospitals. There is a consensus that change must come, although of course there is no consensus on the detail of change. An example of that concerns the Guy's-St. Thomas's future, which is still subject to lengthy consultation which has highlighted a variety of viewpoints.

The Guy's-St. Thomas's dispute, if I may describe it as that, affects even my constituency in south London. The majority of my constituents who need hospital care go to local hospitals. I shall refer to that matter in more detail later. On occasions, however, specialist treatment is needed in a central London hospital. There is certainly affection for such hospitals. From listening to my constituents, it is obvious that there is no clear view on the best way forward. Although I understand the views of those who wish to "defend" the future of Guy's, such views are by no means universal; some people would prefer to see emphasis elsewhere.

I pay tribute to my hon. Friend the Member for Chislehurst (Mr. Sims), who has patiently attended most of the debate and has played a leading role in the Guy's campaign. From his and his constituents' point of view, it is an important campaign. However, I stress that such arguments do not necessarily apply to the whole of south London.

I cannot support the full campaign, which has strangely been called SICK—saving casualty in crisis—the save Guy's campaign. Like my hon. Friend the Minister, I had an acute episode with the hon. Member for Southwark and Bermondsey (Mr. Hughes). The acute episode that I shared with him happened to be on a train, when he came up to me and handed me a leaflet, which I promised to read. I was interested to note that the hon. Gentleman's leaflet states that bishops and actresses support Guy's. It also states that African tribal chiefs support Guy's. I do not doubt that that is correct, but I find it puzzling; the hon. Gentleman's campaign has obviously gone much further than I thought.

The main reason why I take exception to some objectives of the SICK campaign is that the leaflet states that many people regard the closure of Guy's as part of a wholesale destruction of the NHS. That claim is wildly out of touch with reality and does nothing to assist the genuine objectives of those who want a different future from the preferred option for Guy's.

Ms Jowell

The all-party, hospital, trade union and community campaign to save Guy's hospital is different from the SICK campaign, which is based in Southwark communities. Ten years ago, they were promised that, when two of their hospitals, New Cross and St. Olave's, were closed, Guy's would continue as their district general hospital. There is very strong feeling in the communities of Southwark that the national health service is disintegrating and that promises are being broken.

Mr. Merchant

I thank the hon. Lady for clarifying that point, but it does not change my view on the leaflet produced by the Save Guy's campaign and SICK. It is a joint leaflet carrying both logos, so presumably everything that it says represents what both groups feel. I was making the point that such statements do not convince me that the arguments are genuine enough for me to lend my support to the Save Guy's campaign, even though I understand and have sympathy with many of its objectives.

Mr. Jenkin

All hon. Members feel an emotional attachment to these great institutions with their established history and worldwide reputations. Even my constituents, who are on the fringes of a Thames regional health authority, write to me on occasion about their concern about the possible closure and rationalisation of London's teaching hospitals. When I explain to them, however, that rationalisation of London teaching hospitals is necessary in order that more of their health services should be based locally, they understand that it is not the emotional but the practical case that must rule our hearts. We must go on advancing the practical case and not allow emotion to rule over practical decisions.

Mr. Merchant

My hon. Friend is right. I am grateful to him for making that point, to which I was about to move. If it applies to his constituents, it applies also to my constituents, who are London constituents and who, nevertheless, would always prefer, if possible, to have treatment locally.

I imagine that it will always be necessary for some of my constituents to seek specialised treatment in central London hospitals, but I would prefer that far fewer of them need to do that in the future than have done in the past. It is interesting that the people who are strongest in campaigning to freeze, if you like, the position of the centres of excellence and central London teaching hospitals are the people who have had treatment there. Understandably, they have a warm feeling about that experience. When given the option, people who know that they might need similar treatment say that they would prefer to be treated locally, if possible, rather than centrally. We must take those people most into account.. They are the future patients. We have to think of their interests in constructing the best possible health care system in the capital.

My constituency is in outer London in the borough of Bromley, which has a population of just over 300,000. In terms of area, it is the largest London borough. The interests of my constituency are at least of equal importance to the interests of inner London, despite the fact that inner London so easily dominates the debate: I want the reorganisation of central London facilities, which is inevitable, to be carried forward strictly in tandem with the needs of outer London and with provision in outer London.

I should like to refer to existing health provision in the London borough of Bromley. As reference has been made to the largest and most prestigious hospitals, perhaps I can refer to one of the smallest hospitals in the Greater London area in Beckenham. I am not an expert in this, but the problem in that part of outer London—and I dare say that it is reflected in many other parts of outer London—is that hospitals are wrongly placed and in many cases very old. No one needs to be blamed for that. Population and health provision change. The sort of facilities that are available need to change and things will inevitably become out of date and need to be revised. It is important that, when that revision takes place, it matches present and future requirements rather than serves a purely nostalgic purpose.

There are four hospitals in Bromley. One is an accident and emergency hospital on a cramped site almost in the middle of the town. Access is extremely difficult, and physical reasons make it impossible to find a practical way to expand it. The second hospital is Orpington, which is on a very large site, much larger than the buildings need, and its location means that it serves only a corner of the borough. The third is Farnborough hospital, which is on a good site and reasonably well located. But its buildings are Victorian and some of them are huts and the like. It was badly planned and has been developed piecemeal over decades, and clearly needs to be improved. The fourth is Beckenham hospital in my constituency, which evokes great local support but could clearly never hope to provide all the facilities that are required nowadays.

Since the setting up of the Bromley hospital trust, great efforts have been made on future planning to improve the situation for residents of the borough. I place on record my appreciation for the work of the trust's chief executive, Mark Rees, who has provided a first-class service to me and to my hon. Friends and who makes great efforts not just to provide the best service for today, but to improve it for tomorrow.

There is clearly merit in centralising facilities in a borough, especially for the major acute services, and the provision of such facilities has caused the borough great problems. The original plan was to build a new district general hospital on the Elmfield site but, sadly, that opportunity was lost, though only on planning grounds. It was supported by the local authority and was obviously the best plan from the health point of view, but I am afraid that it was prevented by a rather cynical appeal to self-interest by local Liberal Democrats who put the advantage that they saw in stirring up their own back yard, if I may describe it that way, before the wider health interests of the borough. It was a great pity that idea was lost.

As a result, no other new sites are available on which to put a district general hospital—the planning position is as bad as that—and there is therefore a need to develop the existing hospitals. Luckily, there is a possibility of doing that and Farnborough hospital offers the best option. I support that option, provided that alongside it there is proper recognition of the role played by the other hospitals in the borough. They should not be seen as rival hospitals duplicating services but as hospitals providing different but necessary services for proper health provision for local people.

The health trust has promised that the future of Beckenham hospital and that of other hospitals in the borough is guaranteed, so I am not in any sense fighting to prevent a hospital closure. I am seeking to stress the need for the future to be clear and for plans to be adequate. Although the term is not approved by current hospital administrators, I am talking about the provision of a proper cottage hospital in an area with a unique identity. That would provide facilities which would give, with much greater convenience, a whole series of health services to local people. The word that tends to be used now is "polyclinic." I do not like the term, but a small hospital of that type still has a relevant role. It could provide out-patient facilities so that consultants covering a wide range of specialties could come to the hospital and patients could see them there rather than having to travel long distances on public transport facilities which are not always ideal. That fits in with the pattern of overall health provision in London that we have been discussing. Day treatment should be provided at an enhanced level. Specialist clinics should be developed, not just for people in the immediate area, but to cater for wider borough needs. That would take pressure off the other hospitals—a sharing of specialist services. That is already beginning to develop.

There should also be a full array of diagnostic services because that is usually the early stage of a patient's treatment. If that can be handled locally, so much the better for the patient and for the hospital treatment. Last but not least, I would like the hospital to have a small injuries unit. My hon. Friend the Minister referred to small injury units and clinics. I listened with great interest and I was pleased to hear him say that he envisaged an important future for them. There used to be one at Beckenham hospital and it provided a useful service. Sadly, it was lost some years ago, but there is now a real possibility that it might return. I know that the health trust has been examining the issue in detail. Indeed, I view it as a condition that I would want fulfilled if I am to support the overall development that the trust envisages for hospitals in the Bromley area.

Provided that everything is understood, a clear distinction can be made between the sort of services provided by a small injuries unit and those provided by a major accident and emergency unit. Local people would be provided with a viable service, without in any way compromising the major A and E service that would be provided elsewhere. Since I have made that suggestion, I have received a tremendous response from local people, showing how strongly they feel about it and how large is the potential demand. Indeed, I have a file full of letters, which I do not intend to read, showing a clear favourable view.

I want briefly to refer to two other important aspects of London health care. The first is primary care. I have already mentioned the role that a small hospital can play and the specialist services that it can provide. The general practitioner can also provide many of those services.

Ms Judith Church (Dagenham)

Perhaps the hon. Gentleman would be interested to hear about a constituent of mine, Mr. May. He is a second world war veteran who fought for his country, was a prisoner of war and escaped from the prisoner of war camp. He is a man of great fortitude and bravery. He is certainly not fainthearted in any way. However, when he went to his general practitioner to get pain-killing tablets for his back, he was told that they were now available only on private prescription. Perhaps the hon. Gentleman would like to comment on the general practitioner services available to patients such as Mr. May.

Mr. Merchant

It would not be right to be drawn into a medical judgment on one of the hon. Lady's constituents, much though she may tempt me. I was once visited at one of my surgeries by a constituent who complained about his knee. Before I had the chance to ask him what the problem was, he had rolled up his trouser leg to show me his knee and he asked me to examine it. I declined as I did not feel that I was sufficiently qualified.

My point about primary care is that GPs are increasingly able to offer services which in past decades only hospitals could provide. Indeed, a major GP fundholding surgery in my constituency—Elm road surgery—provides a whole range of services which in my youth, many years ago, one would never have imagined would be provided by a GP. Consultants go to that surgery and carry out what previously would have been an out-patient appointment at a large hospital and would have required the patient to travel. That is an excellent advance.

Another point that I must make—I see that I have little time to do so—is about the London ambulance service. It has had serious problems and there are still difficulties, but I should like to record my gratitude—

It being half-past Two o'clock, the debate stood adjourned.