Health Services (London)

HC Deb 05 April 1995 vol 257 cc1735-52 3.30 pm

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

(by private notice) asked the Secretary of State for Health if she will make a statement on the health service in London.

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

The decisions that I announced yesterday follow four separate statutory consultation exercises about hospital changes in south and east London and around Barnet and Edgware. In each case, the decisions measure up against the Government's key objectives for improving the health service in London—to strengthen specialist services by concentrating them in centres of excellence; to preserve and enhance medical teaching and research in the capital; to provide more modern acute hospital services closer to the major centres of population; and to release money to increase investment in family doctor and community health services which are badly needed in parts of the capital.

Those key elements of the Government's strategy will be familiar to the House. I set them out in a statement at the time of the publication of the Tomlinson report, and again when I announced my response. They have been frequently debated. I said on those occasions and I say again: the objectives of this strategy enjoy widespread support within the clinical and academic worlds and from independent commentators such as the King's Fund. The need for change in London is widely recognised, and widely recognised as long overdue.

I hear and understand the concerns that have been expressed, not least by right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke). We considered very carefully the points made during the consultations, including those made by right hon. and hon. Members in their meetings with the Minister for Health and me. In particular, I was struck by the points made about the pace of change and the extended time scale of some of the announcements yesterday respond to those points.

Let me make it absolutely clear that no accident and emergency facility, or indeed any other, will close until Ministers are satisfied that the alternative facilities are not only available but capable of providing an improved service for patients.

My right hon. Friend asks specifically about the financial implications. The changes announced yesterday will be backed by £400 million of capital investment. That is on top of the £210 million that we are already spending on improved primary care. That is a substantial investment in a modern health service.

That money will buy, among other things, a new NHS hospital for Greenwich, an upgraded hospital in Barnet, complete with a state-of-the-art accident and emergency department and a world-beating centre for neurosciences and neurosurgery at King's. It will support the changes at the Royal Hospitals trust and Guy's and St. Thomas's, which will develop them as centres of supreme excellence in treatment, teaching and research. In addition, we are investing substantially in other hospitals such as the Homerton, Lewisham, King's and the Royal Free.

Aside from the direct clinical benefits, we expect those changes to lead to substantial revenue savings which we estimate will be of the order of £75 million each year once the changes are complete. That is money which can and will be invested elsewhere in the health service, both in community health services in London's areas of greatest need and outside the capital.

I say to the House that, at the moment, rather than getting £75 million out, we are putting in £28 million each year, supporting the duplication and fragmentation of services around the four areas covered by my announcement. That must be a good exchange by anyone's standards.

For St Bartholomew's and the Royal London, capital investment will total nearly £240 million. It is expected to deliver revenue savings of £30 million a year; the current subsidy for the trust is about £8 million a year.

Let me say to my right hon. Friend that the changes that I announced yesterday, which take our strategy forward, are not primarily about finance. [Interruption.] These changes are about improving the quality of care. They are about better specialist services, where medical expertise is enhanced by bringing clinicians together to benefit from each other's ideas; they are about better teaching and better research, and about linking world-class hospitals to multi-faculty colleges; they are about equipping modern hospitals to respond more flexibly to the pressures that they face, and harness the awesome advances in medical technology; and they are about providing more health care where Londoners need it most badly—in their communities, their doctors' surgeries and the streets where they live. It is on that basis that I made my decisions.

Change is never easy, but to fail to deal with the need for change in London would be to fail to deal with the needs of Londoners. I am determined that, as a result of these changes, we shall have a health service in London that is fit for the 21st century, in which we can all take great pride.

Mr. Brooke

I thank my right hon. Friend for answering my question. Her policy of rationalisation and the concentration of specialties in London enjoys considerable support among Conservative Members; against that background, will she answer a number of specific questions about Bart's?

First, can my right hon. Friend tell us anything about the current state of negotiations with the City corporation about a continued health service on the Bart's site? Does she recognise that Bart's is a national—and, indeed, international—asset, and that, in a post-industrial society, such assets are of great importance in communicating British medical excellence to the world?

Secondly, can my right hon. Friend outline as far as possible—I recognise the difficulties—her plans to ensure that the national asset to which I have referred is protected and enhanced in the merger at Whitechapel? What will be the future deployment of the historic site at Smithfield? I use the word "historic" in a living rather than a heritage sense.

Mrs. Bottomley

I appreciate my right hon. Friend's recognition of the need to rationalise and concentrate services. That message has been repeated time and again over the past 80 years, but with increasing intensity in recent years.

My right hon. Friend asked what stage had been reached in discussions with the City corporation. I am glad to say that a memorandum of understanding is likely to be agreed between the corporation and the local health authorities next week. Their ideas have been based very much on the Newchurch report, in the hope of a practical response to the present-day needs of the local community.

My right hon. Friend referred to the national and international significance of the hospital's ethos and work. I said explicitly in my statement yesterday that I wanted that ethos and culture to be preserved and enhanced during the move—albeit a move to the Royal London. That tradition is important, and, as my right hon. Friend knows, I fully appreciate the long history of St Bartholomew's; but other hospitals have been able to move successfully.

For example, St George's moved to Tooting, although that took 21 years. I do not think that 21 years of indecision would benefit my right hon. Friend's constituents, or the eminent professionals who work at this distinguished hospital.

As for the site, I announced yesterday that a project team would look for practical options fitting to the site on which there has been such a history of excellent medicine over many hundreds of years. I can inform the House that Sir Ronald Grierson has agreed to chair that committee. I hope that Lord Rees-Mogg will also be a member of the committee as well as a number of other distinguished academics and clinicians.

Mr. Peter Shore (Bethnal Green and Stepney)

The right hon. Lady should know that her announcement of the closure of Bart's and the London Chest will be greeted with dismay and anger in east London. We do not expect our services to improve; we are fearful that they are deteriorating.

When the right hon. Lady says that there is widespread acceptance for the plans, is she not aware that, apart from what the first King's Fund report said and Tomlinson backed up, a succession of reports since then have revealed that, far from being over-bedded, London is short of beds in a major way?

When the right hon. Lady speaks of having gone through a consultative process, is she not aware that, at every stage in the consultation, her proposals have been resisted by the people directly concerned and by the community health councils? Is it not becoming a farce to speak of consultations which have no effect whatever on the area authorities, the regional authorities or the Secretary of State herself?

Mrs. Bottomley

It is my task to make sure that decisions are taken only when, after careful discussion, I am satisfied that they will lead to improvements in health care. As the right hon. Gentleman knows, I know his part of London extremely well. I know the dearth of primary and community services and the benefit to his constituents of the £210 million being invested in primary care in London.

As for beds, all reports have reinforced the dilemma of excessive duplication of specialty beds. The difficulty is that the specialty beds are in units below the size necessary to gain the full benefits of research teams and managing a modern health service.

When the right hon. Gentleman considers the specialty reviews chaired by eminent clinicians, many of them leading members of the royal colleges, he will see time and again the message repeated—as it was in the King's Fund report and the Tomlinson report—that the duplication and fragmentation of the specialty units mean that we do not get the maximum benefit from the substantial professional and financial commitment that we are putting into health care in London. To achieve precisely that excellence and quality of care, it is necessary to take those decisions.

Sir John Gorst (Hendon, North)

Does my right hon. Friend accept that democratic politics is about delivering to people what the majority want, and not about telling the majority of people what they should have? Does my right hon. Friend not accept now that she is doing the wrong thing, in the wrong way, at the wrong time and in the wrong place? Finally, now that my right hon. Friend has had time to reflect on her precipitate decision, which she clearly took after seeing my colleagues and myself with a weekend intervening, will she recognise that perhaps the decision was the wrong one? Will she now reconsider it?

Mrs. Bottomley

I well understand my hon. Friend's strong commitment on behalf of his local hospital and the service it has provided to his constituents. I also heard my hon. Friend saying that he has had 25 meetings on the issue.

The need for modernising the health service and bringing together state-of-the-art accident and emergency departments is repeated time and again by clinical standards advisory groups and the teams of professionals, who time and again argue about the better clinical outcome of a consultant-led service. I know that my hon. Friend felt strongly about questions of timing, transport, the ambulance service and the improvement in primary care. I hope that he will feel that, in my announcement yesterday, I have indeed considered all those elements of his requests. He knows that the health authority will be consulting about what further uses could be developed at the Edgware hospital, to fit the needs of the community not only for today, but for the next century.

Mr. Simon Hughes (Southwark and Bermondsey)

Does the Secretary of State accept that she made a grave mistake by not coming to the House to make her announcement? It is the national health service, not the Secretary of State's health service, so should not serious weight be given to the public's views about the proposals on which she consulted? If, for example, in relation to Bart's, Guy's or any other hospital, 1 million-plus people take one view, and, as in the case of Guy's, 23 people take a different view, and if the right hon. Lady then takes the view of the 23, would it not be wrong to say that she has listened to the public consultation?

The right hon. Lady said that accident and emergency units would close in five years' time, on the assumption that the remainder of the health service in London could provide an alternative. What guarantee can she give that there will not be just as much need then for the units that are in place now?

How much of the money that the right hon. Lady has announced is new money? Is it not the case that none of the capital money is new money? In view of her letter to the chairman of the South Thames regional health authority, it appears that the local commission's bid for another £29 million as the minimum needed to make the changes viable will have to be met from the regional budget, not by any additional Government money being provided as a result of her announcement yesterday.

Mrs. Bottomley

In the hon. Gentleman's lengthy contribution to the debate in the House a week ago, to which my hon. Friend the Minister for Health responded, he praised the consultation process in his area. The reconfigured proposals and the change of timing have arisen very much out of the consultation process, listening to the concerns of local people. However, the argument remains about the need, over time, to concentrate essential in-patient acute services on one site and to develop at the Guy's end a state-of-the-art centre for diagnostic day-care treatment and services.

I believe that the hon. Gentleman will see that development increasingly being regarded with great respect, not only in this country but internationally. He knows that there are proposals for Guy's to accommodate some elective work and some mental health services, over time. However, above all it is the commitment to integrating clinical services with research and education—having the research campus at the Thameside site—which is spoken of with great respect and excitement by many people in the clinical field.

On the question of accident and emergency departments, I refer the hon. Gentleman to the comments of Sir Norman Browse, the president of the Royal College of Surgeons, and Howard Baderman, a doctor and an adviser to the chief medical officer, who time and again talk about the great number of A and E departments in London, far above need—[HON. MEMBERS: "No."] I am quoting Sir Norman Browse and Howard Baderman. They also talk about the importance of quality, and of having a consultant-led service.

The hon. Gentleman is aware that there will be no change in his A and E department until we are satisfied that proper alternative arrangements are in place to provide the service that his constituents need.

On the question of money, over time there is certainly no justification for London having a subsidy in transitional relief. London needs to come into better balance. The capital money is new money, to be developed over time to ensure that we can actually deliver world-class hospitals. It is new money.

Several hon. Members

rose—

Madam Speaker

Order. I cannot allow these long exchanges to continue with so many Members seeking and deserving to put questions to the Secretary of State. I ask for brisk questions to the Secretary of State. I hope that she will also co-operate by giving brisk replies.

Sir Rhodes Boyson (Brent, North)

Is my right hon. Friend aware that I have not yet met one individual in my constituency who agrees with the changes? Secondly, years ago I fought to retain grammar schools because of their long traditions. Hon. Members on this side of the House are destroying the same traditions in the hospitals, which is a form of vandalism. Is she aware that many people do not believe—and figures support their view—that we have too many hospital beds in London?

My constituents want little hospitals that they can get to and walk to, and where they can visit their people in the evening. That is the factor involved in the attack on Edgware hospital. From there, my constituents must drive six and a half miles to Northwick Park hospital. It will take anything up to one and a quarter hours. One could be dead by the time one arrives.

Mrs. Bottomley

I accept my right hon. Friend's comments about his constituents' attachment—which I share—to the existing pattern of services, but I can refer only to the comments of Professor Nick Bosanquet, who said: London health services may have had a glorious past but their quality in the future depends on our willingness to face up to the difficult choices now. Mounting evidence exists about the clinical outcomes of different styles of treatment and patterns of care. It would be negligent of the holder of my office not to take seriously mounting and pressing evidence from leading clinicians.

My right hon. Friend will know not only that, in his region, he has access to Northwick Park, the Royal Free and the brand new Barnet general hospitals, but that the service at Edgware hospital will continue to provide for the vast majority of patients who use it. It has an out-patients department and a minor injuries clinic, and it will look to see what other services it can provide in relation to the needs of an increasingly aging population. Those are the health needs of today and tomorrow.

Mr. John Austin-Walker (Woolwich)

Is the Secretary of State aware of both the anger and incomprehension among staff at the Brook hospital, particularly those in the neurosurgical team? Why have neither she nor officers of her Department held any discussions with that team, and why have they ignored all its advice to her Department, especially in relation to its concerns about the separation of neurosurgery from other acute and trauma work?

When she says that she wishes to place services nearer to the patient, is she aware that regional specialties at Brook hospital serve south-east London and Kent? Does it make any sense to move them closer to central London, so that no neurosurgery unit exists from Dover to Lambeth?

Mrs. Bottomley

I am particularly pleased to respond to the hon. Gentleman's point. The neurosciences were the one area where we did not accept the specialty review proposals that I described. That was because the recommendation of Sir Michael Thompson, the vice-chancellor and principal of the university of Birmingham, who led the London research review, identified the institute of psychiatry at Denmark Hill as a unique opportunity to build a centre of excellence.

I have received a letter from Sir Michael Thompson, in which he says—

Madam Speaker

Order. The Secretary of State will have seen the number of hon. Members who wish to question her on the statement. I have already asked her to give brisk answers, and I hope that she will paraphrase the letter.

Mrs. Bottomley

Very quickly. Sir Michael merely said that the chairman of the expert group on neurosciences, Professor Ingrid Allan, stressed the eminence of the institute and the special health authority, and, in particular, its high reputation from an international point of view. He said: You are to be congratulated on your action, which will create a unique centre where the results of a leading research group will more readily benefit the patients of the NHS.

Mr. Roger Sims (Chislehurst)

Does my right hon. Friend recall that, when she made a statement 13 months ago, I complimented her on grasping the nettle of London hospital reorganisation? I continue to admire her courage in tackling the issue, but may I plead with her, in doing so, to show rather more sensitivity than she has in the past couple of days? She has made several references to consultation, but does she agree that consultation implies listening to what people have to say and taking account of their views?

My right hon. Friend must be aware of the volume of opposition—much of it well informed and well argued—to the proposals made by Guy's and St. Thomas's hospital trust as to the reallocation of services between the two sites. Will she take that into account? May I invite her, as I suspect that she may not have done so, to read the report of last week's debate, in which I and a number of other hon. Members raised several pertinent concerns about Guy's and St. Thomas's, to which we have received no response whatsoever? Will she consider them, and my alternative suggestions as to the way forward? May I urge her, even at this late stage, to think again?

Mrs. Bottomley

I thank my hon. Friend, certainly for his comments to the effect that the nettle has to be grasped. There is little doubt that delay and uncertainty will not serve London's health professionals or patients. Change has to be addressed. It is always possible to look for further options. These decisions are finely balanced, and the one that he describes is one of the most finely balanced, as I think he will remember I said explicitly in my previous statement. I can assure him that I have read the debate of a week ago, which was answered by my hon. Friend the Minister of State.

We have taken the view that the issues raised have been thoroughly and properly addressed in what the hon. Member for Southwark and Bermondsey (Mr. Hughes) identified as a particularly thorough consultation process. It is now for the trust, in association with the local health authority, to start specifying in a more detailed manner the way forward, but what I am clear about is that Guy's will remain an outstanding name associated with research and education.

The opportunity, for example, to bring the school of nursing to join the medical school is one of great importance, and, as King's joins the medical school, the advantage for medical schools outside London of associating medicine with biomedical sciences will lead to even better standards.

Ms Tessa Jowell (Dulwich)

May I return to the Secretary of State's rather evasive answer about money? So that no one is in any doubt, will she confirm that she will make £29 million available as requested by the Lambeth, Southwark and Lewisham health authority—extra, new money that has not been raided from any other budget? Will she give the House that unequivocal assurance?

Mrs. Bottomley

What I have made clear is that the money will be available to invest in the capital programmes necessary for the changes envisaged. After all, this is the Government who have put £1.3 billion into the health service this year, and that is new money. We would not have made our announcement until confident that, year on year, the money—the taxpayer's money—would indeed be available. In the case of the Guy's and St. Thomas's project, that amounts to a new capital programme of £90 million.

Mr. John Marshall (Hendon, South)

My right hon. Friend will know of my concern about Edgware hospital. This afternoon she has stressed the need for greater primary health care, so will she say how much additional money she intends to put into additional primary health care in Barnet?

Mrs. Bottomley

My hon. Friend will have heard me say that the total amount now going into primary health care is about £210 million, funding about 1,000 new initiatives. The range of family doctor services and hospital-at-home schemes throughout London is phenomenal. I believe that the figure for my hon. Friend's constituency is £15 million, but I am somewhat hesitant to say so dogmatically, and I will confirm the figure to my hon. Friend.

Ms Diane Abbott (Hackney, North and Stoke Newington)

Is the Secretary of State aware that nothing has made this Government more unpopular in London than her complete unwillingness to listen on the matter of hospital closures? Is she aware that ordinary people in Hackney are very angry about the closure of Bart's, because promises of money for the Homerton and promises of money for primary care are just promises? We know that, in losing Bart's, we are losing access to a world-class facility.

Mrs. Bottomley

The hon. Lady has had a phenomenal investment programme at the Homerton hospital, in the area where people live. With the Homerton hospital, she is in the same position as her right hon. Friend the Member for Bethnal Green and Stepney (Mr. Shore). Lewisham hospital and King's College hospital have multi-million pound programmes, because health care must be delivered where people live.

It is outrageous for the hon. Lady to say that her constituents should be destined to travel needlessly for routine health care. I and my hon. Friend the Minister for Health have visited Homerton hospital, so we are well aware of the enormous investment programme and the changes under way there.

Mr. Peter Bottomley (Eltham)

The hon. Member for Woolwich (Mr. Austin-Walker) spoke about the regional specialties that are presently at the Brook. May I turn to the local needs, and thank the Minister of State and his predecessor for helping to get the co-operation in buying the Queen Elizabeth Military hospital so that it can succeed the Brook on the other side of Shooters hill, and bring much of the acute work from Greenwich district hospital?

Mrs. Virginia Bottomley

I thank my hon. Friend. There will he a significant improvement. As he well knows, the present buildings are quite unsuited to the delivery of modern health care. His constituents and people in Greenwich will undoubtedly benefit.

Mr. Nigel Spearing (Newham, South)

Would the Secretary of State like to know that the people of east London will be outraged by her remarks about casualty and emergency? Is she aware that she is closing casualty in central London, while in Newham, where people do live, we have an eight-hour wait for casualty and emergency?

In respect of concentration on one site at Whitechapel, is the Secretary of State aware that she and her Department have consistently made wrong calculations about demand for the ambulance service? If she can make wrong calculations on a relatively simple matter, should she not retain the buildings at Bart's and the London chest hospital until the demand is shown? Would it not be irresponsible for her to do anything else?

Mrs. Bottomley

The hon. Gentleman has repeatedly and rightly referred to the problems faced by the London ambulance service. There has been significant improvement in the standards being delivered by the service, and we hope to see more. He will also know that the outcome for individuals in an accident depends largely on a paramedic arriving swiftly at their side.

Thereafter, having a high-quality accident and emergency department with all the specialty services around it is important. The hon. Gentleman will know that London is very much better provided with accident and emergency services, even after any number of changes being debated today, than other parts of the country.

Mr. Richard Tracey (Surbiton)

My right hon. Friend well knows that primary care in London has, for far too many years, been worse than it is anywhere else in the country. The quid pro quo for Londoners of all these changes is that primary care should be brought up to the standard of the rest of the country. Will she now accelerate the movement of resources even more quickly into the provision of primary care services all over the capital—in outer London as well as in inner London?

Mrs. Bottomley

I thank my hon. Friend. The work undertaken by the London initiative zone and the primary care support force, which is always slower to start with, will now accelerate. One thousand projects funded to the tune of £210 million have been an excellent start. With the new regions, we want to ensure that the changes are spread, as my hon. Friend says, not only in inner London, but in outer London and through into the home counties. Londoners must have the standard of primary care that others have.

Ms Glenda Jackson (Hampstead and Highgate)

As the Royal Free Hampstead trust in my constituency will, according to newspaper reports—which are increasingly becoming the only way of obtaining information from the Department of Health—be expected to take up the slack occasioned by the closure of Guy's and Bart's, certainly for accidents and emergencies, will there be new money for the Royal Free hospital for the undoubted expansion of the capital scheme and the undoubted increase in staff and nurses? Will the Secretary of State therefore cancel the proposal to reduce the ambulance service in Cressy road in my constituency from its present six ambulances to two?

Mrs. Bottomley

I always find it ironic when Labour Members preach to us about resources. I happened to work with the health service when the Labour party was in power and cut nurses' pay and money for the health service. The Conservative party puts much more money into the health service.

As I am sure the hon. Lady knows, her health authority is currently deciding that it wishes to send more patients to the Royal Free and take them away from some of the hospitals that they used to use. We have equitable funding, in which money is allocated to the London health authorities, taking account of their need. It is a national health service, and it is only right to have a national approach to the allocation of resources and for that money to be spent fairly and effectively.

Mr. Hugh Dykes (Harrow, East)

My right hon. Friend has some arguments in her favour on central London hospitals. She has not succeeded as a senior member of the Cabinet, because, having listened to hard-faced accountants and bureaucrats in her Department and elsewhere, she has not then taken her own essential, human, social, clinical, medical and political judgments.

That is why I am glad that you, Madam Speaker, have given me permission to raise on the Adjournment tonight the future existence of Edgware general hospital. The proposal to close the accident and emergency unit is outrageous. Consultations with the local public were dismissed out of hand by Sir William Staveley in his regional health authority final consultation meetings. My right hon. Friend must think again about the proposal—it is different from central London; we do not have enough medical facilities, and the other hospitals are too far away.

Mrs. Bottomley

My hon. Friend will clearly have time to develop his arguments at even greater length this evening. Decisions are made on the basis of improving the quality of clinical care. He will know that the development of a massive £29 million new hospital in Barnet will have an impact on the provision of services locally.

But Edgware hospital will continue to provide for at least half the accident cases who can be treated without a specialist service, and about 80 per cent. of those who use the hospital for out-patient appointments. We believe that it will be able to develop even greater services in response to the needs of an aging population in the light of the consultation that I know the health authority intends to begin shortly.

Mr. Nick Raynsford (Greenwich)

The Secretary of State in her statement stressed the fact that a new hospital would be opened in Greenwich. She conveniently forgot to mention that the price paid would be the closure of two existing hospitals, as well as the loss of the two regional specialty units.

Does she not recognise that the overwhelming weight of local opinion argued that two hospitals were necessary in Greenwich, and that two into one would not go? Does she not recognise that her decision flies in the face of local opinion in Greenwich as well as everywhere else in London? The people of London are sick to death of seeing their health service being cut, cut and cut again by a Minister who puts finance ahead of every other consideration.

Mrs. Bottomley

In recent years, the people of London have seen record levels of immunisation, cancer screening, treatment and care. It is no good the hon. Gentleman dismissing that as though he disregards the evidence.

Mr. Raynsford

Record waiting lists.

Mrs. Bottomley

Last year, there was a 25 per cent. fall in one-year waiters. The hon. Gentleman is right— there is more to do. The health service needs rationalising, just as health services in similar capital cities around the world need rationalising. It is clear that the Labour party will never be a party of government, because it can only be a party of protest. Facing the issues fairly and making difficult decisions is part of government. The Opposition have the luxury of constant populist protest.

Mr. Alan Haselhurst (Saffron Walden)

Has not the population of London fallen over several decades, with many people migrating to counties like Essex? Is it not equally true that local health authorities in Essex and the other home counties have had to make difficult decisions on rationalisation and the improvement of their health services, and they have had to do so without the benefit of full and fair capitation, because money is also being tied up in London in a system which, as yet, is unreformed?

Mrs. Bottomley

My hon. Friend is exactly right. I have the responsibility for a national health service. The problems in London have occurred because the population has declined overall over the decades. People in the home counties would rather go to excellent hospitals closer to home. Medical advances mean that lengths of stay have fallen dramatically. New technology and diagnostic and day techniques mean that the need for beds and buildings is not the prime criterion. We want appropriate modern facilities for a top-quality health service as close as possible to where people live.

Mr. Jim Dowd (Lewisham, West)

Apart from asking the Secretary of State why, if this is such good news, she had to be dragged kicking and screaming into the House to make this statement, is she aware that Lewisham accident and emergency cannot cope as it is today, and that the regional health authority admits, in its own curious words, that it is "undersized"? The investment planned to cope with the additional burden as a result of the closure of Guy's could be used today to make it serve the purpose and needs it faces at the moment, let alone what will happen when Guy's closes.

What can the Secretary of State say to the people of Lewisham, who have been involved, for the third time in five years, in a major consultation exercise involving acute service provision in London, only to see their views completely and utterly disregarded?

Mrs. Bottomley

The hon. Gentleman will know that there has been formidable investment at Lewisham hospital. Similarly, King's hospital—which some of the hon. Gentleman's constituents may use—has experienced £8 million-worth of investment. There has been a £3 million investment at Lewisham. That is a hospital in which we are investing close to where people live.

At the same time, the hon. Gentleman will be aware that a significant number of people still use A and E departments in London because the primary care services are not yet good enough. He represents an area which has a formidable programme of investment in GP and primary care services. I believe that that is the way to a better balanced and a better-quality health service for his constituents.

Mr. Nigel Forman (Carshalton and Wallington)

Since the main arguments for these controversial changes rest on academic and clinical considerations, would my right hon. Friend consider asking the senior academics and clinicians to go out and campaign for the changes? If they are prepared to advise her in private and in reports that this makes sense from a medical and clinical point of view, should they not speak in the same vein?

Mrs. Bottomley

My hon. Friend has made a point of great importance. He will be aware that Lord Annan, Lord Flowers and Sir Stuart Sutherland have spent a great deal of time trying to deliver precisely that objective. Four multi-faculty colleges with the hospital clusters around them is the way to provide world-class centres for research and education. The report from the leading members of the royal colleges in respect of delivering the change has been extremely important and significant. However, I echo the remarks of my hon. Friend: the louder they speak, the greater confidence that will carry.

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

As someone who has been, and remains, a long-standing patient at Bart's, and as someone who spent several weeks being treated on its wards; as someone who has spoken to nurses, doctors, administrators, and patients and visitors on the wards and the general public downstairs in the A and E section of Bart's, can I tell the Secretary of State that the overwhelming opinion in Bart's is that the hospital should stay open? Why does she insist on taking on public opinion in that part of London where people say, "Let us keep our hospital"? That is what the people are saying and that is what they want. Why can they not have it?

Mrs. Bottomley

I totally accept the deep loyalty felt by people who work in hospitals, particularly those who work in Bart's, as my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke) spelled out so forcefully. However, if we are to have a comprehensive service, free at the point of use and able to pioneer new treatments, such as gene therapy for cystic fibrosis, artificial livers at King's and the new breakthroughs identified by the Medical Research Council, we must address the need for change. That is why the Wellcome Trust, the Medical Research Council and many others have commended the commitment to address those underlying issues.

The hon. Gentleman is right, in that there is a tension between the wishes of local people and the need to deliver clinical excellence. I believe that I must be guided by the need to provide the best possible clinical and health care service for the people of this country, but that we should do all we can to ensure that we take people with us, and that there is a warm welcome for them as they come together on another site.

Mr. Tim Yeo (Suffolk, South)

Is my right hon. Friend aware that, outside London, it will be regarded as good news that she has taken the decisions, which have been made more difficult by the fact that so many of her predecessors ducked them? Does she agree that, even after all those changes have been made, London will enjoy a network of hospitals that will be the envy of the rest of the United Kingdom? Does she further agree that, for the average Londoner, the urgent need is to improve the primary health care system, exactly as she has proposed?

Mrs. Bottomley

Yes.

Ms Joan Ruddock (Lewisham, Deptford)

Will the Secretary of State tell the House what precise arrangements she believes would have to be put in place before the accident and emergency unit at Guy's could be closed? What would be the cost of converting Philip Harris house for the new arrangements that she proposes, and how much money from charitable funds would have to be repaid?

Mrs. Bottomley

I made it very clear that, before it will be possible to close the A and E unit at Guy's, there must be significant improvements in the ambulance service, together with a judgment, connected with the improvement in primary care, as to the likely use and capacity of the St. Thomas's A and E department. Of course, that is one of the largest units in London, taking about twice as many ambulance cases a day as the unit at Guy's. The hon. Lady will remember that, when I made my statement a year ago, that was one of the key factors in deciding which should be the primary site for the acute in-patient hospital—a strategy supported by people on both sites.

Philip Harris house will be used for about 75 per cent. of its original purposes, and I am pleased to say that the special trustees have said that they will support the plan, and are discussing the possibility of contributing to the intended modifications. Other special trustees will consider their position.

Ms Ruddock

What will it cost?

Mrs. Bottomley

The modification may cost about £10 million, although that could be a high estimate.

Sir Edward Heath (Old Bexley and Sidcup)

Much as I should like to deal with some of the more general aspects of the statement, especially the political implications for those who represent London seats, I shall restrict myself to one particular aspect—the closure of the Brook hospital, and the specialist neurosurgery required, which, according to the programme, will now be supplied by King's. All the specialists to whom I have spoken—and several have been on the telephone to me today—are extremely worried about that prospect, because of the distance to be travelled by what are usually acute cases.

As my right hon. Friend knows, over the past two weeks there have been two incidents in which patients have had to be taken long distances. One patient in Maidstone had to be taken to Southampton for treatment, and the other, from Sidcup, had to be taken to Leeds. I shall not go into detail about those cases, because some of the events are the subject of legal activity. However, the thought that in future all such cases will have to be taken to King's frightens the specialists.

In London, we are short of suitable beds for specialist neurosurgery. Although King's has specialist services, do we not now have the opportunity to concentrate in the long term on the services required to meet the need in a place that people in south London, Kent and the adjacent areas can use more easily, without having to travel long distances?

Mrs. Bottomley

I hope that my right hon. Friend will bear with me, but I must quote to him something that the chairman of the neurosciences review said—[HON. MEMBERS: "No."] Forgive me, Madam Speaker, but the decisions are too important to be taken without independent, authoritative clinical advice, as I hope my right hon. Friend will agree. He said: The historical fragmentation of neurosciences in London and the south east has limited the development of large tertiary centres of excellence, which is the accepted pattern in the rest of the UK. Whilst much good work is being done in the smaller units, in some fields it is tending to fall behind the rest of the country. It is that unique opportunity to move the service to a research and teaching centre that gives London its prime position not just nationally but internationally. I sought to reinforce the point from the vice-chancellor of Birmingham university, that it was a unique opportunity to have a unique service on Denmark Hill. I believe that that is the proper justification for taking a decision that I well understand that local people might have wished had gone a different way.

Mr. Jeremy Corbyn (Islington, North)

Will the Minister explain to the people of my borough who love, admire and respect Bart's hospital, but who also recognise it as a valuable institution and as their local hospital, what will happen to the land and the site when that hospital is closed altogether? Who will make money from that sale?

Is the Minister aware that there is already enormous pressure on the casualty units at the Whittington, Royal Free and Homerton hospitals and at University College hospital as a result of the closure of Bart's? Is she prepared to close more casualty units and create even longer waiting lists, with more people waiting on trolleys for operations or emergency treatment, as currently occurs throughout north London?

Mrs. Bottomley

The difficulty in London has been created because we have so many small hospitals, and it is much harder to manage the peaks and flows of patient care. At times, there is a great rush to use a hospital, and at other times it is under less pressure. The recent report about neurosciences again made the point that larger units can manage their beds better. That message was reinforced by the inner-London chief executives' report about trying to strike the right balance as we change and move forward.

We measure the outcomes of the service; we now have clear targets in terms of the patients charter. The current service is quite different from that provided in the past, and health authorities must deliver results.

As far as the Bart's site is concerned, I think that I made it clear to my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke) that we have set up a project team to consider options in light of the history of a place which has been associated with state-of-the-art medicine and research. Similarly, I hope that the City of London initiative will show results shortly, with a memorandum of understanding to provide a service for local people.

Mr. David Congdon (Croydon, North-East)

I welcome my right hon. Friend's decision to respond to the consultation document in relation to Guy's and St Thomas's hospitals by extending the time that the accident and emergency service at Guy's will remain open until the end of 1998.

As to Bart's and the Royal London hospital trust, as an outer London Member I am concerned at the enormous capital investment that is involved. My right hon. Friend cited the figure of £240 million. However, my recollection is that the consultation document referred to a revenue saving in that trust of just over £22 million. Is my right hon. Friend satisfied that that represents good value for money? Will she consider whether some of the other options, which might involve a rationalisation against both sites, merit further deliberation?

Mrs. Bottomley

I can give my hon. Friend a very clear assurance on that front. He will know that the hospitals involved have a considerable backlog of maintenance, amounting to about £87 million. We estimate that the gross capital spend would be about £239 million, and that land sales would realise a considerable sum. The revenue savings would be about £30 million per year, and that investment is very justified.

I must make it clear that the guiding principle is not efficiency or streamlining costs, important though those issues are: it is to concentrate centres of expertise so that they can compete into the next century.

Mrs. Barbara Roche (Hornsey and Wood Green)

Does not the Secretary of State realise that everything that she has said this afternoon is completely at variance with the everyday experience of Londoners? Why has she failed completely to answer the question posed by my hon. Friend the Member for Islington, North (Mr. Corbyn), who asked what the knock-on effect would be for hospitals such as the Whittington, which serves my constituents? Its services are already overloaded, and it is currently cancelling acute operations because it has run out of money. How will the Secretary of State address the needs of people such as my 78-year-old constituent whose prostate operation was cancelled for that reason?

Mrs. Bottomley

There are problems with the health service in London, which is why it is so necessary to address change. The other day, the King's Fund said that there are real problems in developing primary care and concentrating specialty services. To stand still, or allow the service to fossilise, will not address the real needs of the hon. Lady's constituents or those of my hon. Friends in developing a health service fit for the 21st century.

As for the hon. Lady's constituents, there has been a fall in the number of people waiting for treatment a long time. There has already been considerable investment in primary care. I hope that that will result in even better standards and quality for the hon. Lady's constituents in the months and years ahead.

Mr. John Whittingdale (Colchester, South and Maldon)

Is my right hon. Friend aware that many of my constituents must currently travel up to 60 miles to receive treatment at more expensive specialty units in London? Will she confirm that rationalisation of hospital provision in London is a necessary first step to establishing new specialty centres outside London and closer to where large numbers of people live?

Mrs. Bottomley

It is increasingly true that people would rather be treated closer to home. Rapid investment in the health service throughout the country, and certainly in the home counties, means that care for which previous generations travelled to London can be provided locally. That is precisely the dilemma. Provided that we ensure that London centres maintain a prime position in research both nationally and internationally, some of my hon. Friend's constituents will want still to receive treatment in London for state-of-the-art, pioneering or perhaps experimental care—but they will want routine health care close to home.

Mrs. Margaret Beckett (Derby, South)

After all the comments, I hope that the Secretary of State realises that her case is as dubious as her excuses for not putting her case to the House. Will she acknowledge that even the proposals that stem from the Tomlinson review have been widely attacked as wrong and damaging? For example, plans for Edgware hospital were never even part of that review, but result—as do the near-closure of University College hospital and the threat to Bart's and Guy's—from the internal market introduced by the right hon. Lady's disastrous so-called reforms?

Why has the Secretary of State ignored the anger of local people? She is aware that past cuts already mean fewer acute beds left in London than in any other major British city. How many more beds will be lost as a result of the proposals that the right hon. Lady announced today?

Does the right hon. Lady accept that her obstinate refusal to call a halt to closures and to make a fresh assessment of health needs in London is leading directly to the closure of renowned centres of excellence such as the London chest hospital, Bart's, and even Guy's? All known conversions of accident and emergency units to minor injury units have always been a precursor to the hospital becoming a major casualty.

Will the Secretary of State confirm that the East London health authority, whose detailed business case has not yet been put before the right hon. Lady, agreed to proposals to close the London chest hospital and Bart's only if £238 million for redevelopment was absolutely assured? The Secretary of State's letter refers only to that funding being a high priority, which she also said about the funding needed for Guy's and St. Thomas's. Will the right hon. Lady give a categorical assurance that the demands made of her by the East London health authority will be fulfilled?

Does the Secretary of State realise that the proposals for Guy's will leave 17 floors empty, and that the facilities now provided will have to be recreated? Philip Harris house, which has a purpose-built, state-of-the-art cancer unit and renal facilities, will be used for only three years, and 18 desperately needed intensive care units with state-of-the-art facilities that are being fitted even as we speak, will be ripped out as soon as that house is handed over. Does not the Secretary of State realise that that is clinical and financial vandalism?

Will the right hon. Lady find Government time—for the first time in her history as Secretary of State for Health—for a debate on the Floor of the House, once we have an opportunity properly to assess the implications of the proposals?

Mrs. Bottomley

The right hon. Lady is a real example of turning the clock back. Her predecessors in her job recognised the need for change in London. Alongside the right hon. Lady's approach to every other health issue, she is out for consultation or a moratorium. She never faces a difficult decision.

We understand that the Leader of the Opposition is now saying, "No more money." How will the right hon. Lady cope with no more money, no difficult decisions to be faced, support for every protest and the inflaming of every pay claim? Goodness knows what would happen to the health care of Londoners. Those of us, unlike the right hon. Lady, who were working in Brixton and Peckham when there was a Labour Government, were aware of the misfortune of the entire process. I know exactly who would be the first to suffer if ever there were a party such as the right hon. Lady's in government.

We have comprehensively discussed the issue facing London, except that I have not properly informed the right hon. Lady and others of the extremely encouraging progress at University College hospital, which is now under way. It is part of the picture of four multi-faculty colleges with a cluster of hospitals round them.

The issue is not primarily about hospital beds. It is a matter of having the right services in the right place. We need beds. We need low-tech beds, as Professor Jarman has said time and again. That is why it is so important that there are about 1,800 low-tech beds in the pipeline. It is very important that that programme should go forward.

I have given a clear commitment that the money is available. Of course there must be detailed plans before final approval is given. London needs clear progress. We do not need further hesitation. We need to build for the future, for the 21st century. The right hon. Lady and the Labour party offer dither, delay and, once again, interminable review.

Mr. Andrew Rowe (Mid-Kent)

We have just heard locally that we shall have to take another 10,600 houses in the part of Kent which I represent as part of the continuing expansion of the population, which is moving out of London. To hear London Members complaining about a six-mile journey to hospital makes some of us laugh. We are grateful to my right hon. Friend for having set up the necessary changes to ensure that we in Kent are beginning to secure the sort of resources that will make it possible for us to treat ex-Londoners and native inhabitants of Kent to the highest standards, which would be impossible if the changes were not made.

Mrs. Bottomley

I thank my hon. Friend warmly for his remarks, which are precisely to the point. In London, hospital care has been excessively identified with buildings and institutions. In the home counties, there is a much higher standard of primary and community care. We need a better balance. As my hon. Friend has said, when the population moves to the home counties, people are reluctant to travel. As I have said time and again, I am passionately committed to our prime position internationally. This country is the place where breakthroughs take place.

Mr. Hartley Booth (Finchley)

Will my right hon. Friend address the serious transport issue in Barnet, which is the borough in my constituency? There is a physical block in the middle of the borough—the A1. Endless cars and lorries use the road during daytime hours, and that block is life-threatening. Will my right hon. Friend consult the Department of Transport? Will she assure the House that the new accident and emergency department at Barnet general hospital will not open until she is entirely satisfied that lives will not be put at risk because it is not possible to cross a physical barrier?

Mrs. Bottomley

I undertake to my hon. Friend to have precisely those discussions. I have made it clear in my announcement that the decision is subject to completion of the new phase at Barnet, to improvement in primary care, to necessary changes in the London ambulance service, and to being satisfied on transport issues.

My hon. Friend will be aware of the comments of my hon. Friend the Member for Mid-Kent (Mr. Rowe). He said that people from London are often unaware of the much greater distances that people travel to an accident and emergency department outside London. It is getting a paramedic to the scene in the swiftest possible time that appears to be the crucial factor in preserving life.