Health Care (London and South East)

HC Deb 20 February 1995 vol 255 cc22-80

Madam Speaker

I have selected the amendment in the name of the Prime Minister. I have not restricted speeches for either of today's debates. I leave it to the good sense of Back Benchers and Front Benchers to exercise some voluntary restraint so that everyone who wishes to be called is likely to be called.

3.31 pm

Mrs. Margaret Beckett (Derby, South)

I beg to move, That this House expresses its concern at the evidence of continuing crisis of health care in London and the South East; believes that the scale and nature of the crisis stems directly from the Government's failure either to assess the health care needs of the area properly or to plan a programme by which those needs can be met; believes that the process of the internal market and Government-driven so-called 'reforms' are making matters worse; and calls for a moratorium on further closures until a fresh and thorough review has been carried out of the mounting evidence of serious misdirection of health care across the whole of the area. Yet again, it is the Opposition who provide the opportunity for a debate on health care in London and the south-east, both because it is important in itself and because of the light that it casts on the implications for Britain as a whole of Government health policy.

It is important to flush out the Secretary of State for Health to give us her views on these matters. She is fond of talking about stewardship and responsibility, but less fond of exercising them. It is also valuable to have the debate at this time, because we are at a turning point, a crucial point of change.

On Saturday, a large conference discussed the crisis in London health care as the effects of Government policy begin to be felt. In two days' time, the consultation period on proposals to close Bart's hospital will come to an end, and we shall see whether the health authority meant what it said when it suggested that public reaction to those proposals would influence its decisions.

We are on the brink of other, greater change. Decisions will be made against the background of still greater cuts in funding for the authority which controls Bart's, and cuts for other authorities which rank high on the Department of the Environment's list of authorities dealing with high levels of poverty and deprivation. Of course, the debate is also held against the background of the final, full implementation of the Government's dogma-driven policies.

In April, the special health authorities—hospitals such as Moorfields, the Bethlem/Royal Maudesly and the Royal Marsden, which have been cushioned until now from the full effects of Government policy—will face the impact of the Government's so-called reforms, as the full internal market finally comes to London. Londoners await that process with the same anticipation as they once awaited the arrival of Boadicea.

Five years ago, London was the undisputed health care capital of. Europe. The French newspaper Liberation carried out a survey of medical research and teaching in 1989, which put London's medical schools at the top of the European league, above even Oxford and Cambridge. It ranked them as the best in the continent, not just in Britain, and said: the density of its network is such that this premier position is in no way a surprise; the different colleges each on their own cover the full range of specialties. The report went on to refer, rather optimistically, to the one constant which does not change: the supremacy of British medicine. London has always been the key to the top ranking of British medical science. It trains 30 per cent. of new doctors and a quarter of new dentists. Half of all the highest grades awarded in clinical medicine are gained by people who went to university of London medical schools. That is not accidental. London's large catchment population and the concentration of medical resources have enabled the maximum interaction between science and clinical medicine. That has provided the strong base needed to sustain the caseload required for training and development.

In fact, like that other great national institution, football, until recently the hospital service in London was one of our greatest assets—an institution in which London's citizens could take great pride. It is now threatened with disintegration and collapse. Several of the most famous teaching hospitals on which the medical schools depend face closure, including Bart's and Guy's, while others are to be amalgamated. The post-Tomlinson rationalisation could lead to a flight of research revenue and income. Dozens of professors and top consultants face redundancy, and many are leaving London, with the consequent exodus of medical talent.

As with football, so with health care—London is now in danger of being relegated to the international second division. Like hooligans at a Chelsea-Millwall match, the Government set out wilfully to vandalise a service that was once orderly, well managed and widely supported. The question that we want to ask is the same question as that behind the inquiries into the recent England-Ireland game—is the Government's sabotage of London's health service the action of mindless vandals, or are they motivated by extreme right-wing ideology?

Lord Sutch of the Monster Raving Loony party does not seem to be in any doubt. On Friday, he said how disappointed he was that the Conservatives had just pipped his party into fifth place in the Islwyn by-election. He said: We thought we would beat the Tories, but by mistake people voted for the wrong loony party. I must differ from Lord Sutch— the Government are not just loonies, and they are not just hooligans, although the Secretary of State gets called before judges to account for her vandalism of the health service. She and her colleagues are guilty of willful destruction, but it is not mindless hooliganism.

Just like many of the troublemakers at our football matches, the Government are driven by right-wing ideology, which they coldly and deliberately calculate will wreak havoc in our public health service, just as it will create opportunities for those who can profit if what is lost from the public sector is replaced in the private sector— and unlike many of football's troublemakers, the Government are carrying out their strategy with stealth, and in furtive secrecy.

Unfortunately, the strategy's effect on London is especially acute. While London is a centre of medical excellence, it is also a city of harrowing deprivation and savage contrasts between rich and poor. Four out of five of the areas of greatest deprivation in Britain are, according to Department of the Environment indices, in London. Unemployment, a major cause of ill-health, in London is double the national average. Perinatal mortality in London is 74 per cent. above the national average. A third—

Mr. Tim Yeo (Suffolk, South)

Will the right hon. Lady give way?

Mrs. Beckett

In a moment—I am sure that the hon. Gentleman will want to hear the figures.

One third of all those who died from hypothermia in 1992—the latest year for which we have figures—lived in London. Some 75 per cent. of all HIV and AIDS cases are in London; 42 per cent. of United Kingdom reported cases of tuberculosis in 1992 were in London—in itself increased by 13 per cent. since 1988; and 60 per cent. of all Britain's homeless and people living in temporary accommodation are in London.

Being a great metropolitan city also means that London attracts huge numbers of visitors and commuters, all of whom increase the strain on its health service.

Mr. Yeo

The right hon. Lady mentioned perinatal mortality. Does she agree that it is one of the most objective indices of good health that can be applied to any nation and any region of any nation? Does she further agree that, since 1979, there has been a substantial fall in perinatal mortality across the whole of the United Kingdom, and that nowhere is that fall more substantial than in London, where the figure is down from 12.7 per 1,000 to 7.1—a drop of 44 per cent?

Mrs. Beckett

Improvements have been made in perinatal mortality rates. I am afraid that I do not have the figures or the report with me—mind you, Madam Speaker, nor does the hon. Gentleman. He borrowed them from his hon. Friend the Member for Hertsmere (Mr. Clappison), who presumably had the briefing.

Mr. James Clappison (Hertsmere)

rose—

Mrs. Beckett

I shall give way in a minute—one intervention at a time, thank you.

If one considers, in particular, inner-city wards where deprivation is highest, that puts those figures very much into the shade. The hon. Member for Suffolk, South (Mr. Yeo) knows that my point is about the deprivation level across London. The overall average figures have improved, as they have elsewhere. That is what we expect. They improve year on year, century on century; there is nothing new about that.

The hon. Gentleman said that the figures had improved, but he knows that they have not done so where greatest deprivation exists. Although I do not have the figures with me, my recollection is that, under this Government, the position has worsened in some areas of greatest deprivation.

Mr. Clappison

rose—

Mrs. Beckett

I shall give way to the hon. Gentleman. Has he now found some other figures?

Mr. Clappison

Will the right hon. Lady take it from me that the standardised mortality ratio shows that London has an above-average performance in mortality rates? Contrary to what she has said about deprivation areas, the most recent statistics show that the biggest reduction in infant mortality has been among the lowest social classes 4 and 5. The best improvement has been made in those social classes.

Mrs. Beckett

I give the hon. Gentleman the undertaking that I will read carefully what he has said, but it contradicts much of the other published evidence. I hope that neither of the two hon. Gentlemen who have intervened are contesting my basic point about the deprivation level and about the serious problems that occur in London and are concentrated in London, disproportionately even to other inner-city areas in the United Kingdom.

The hon. Member for Suffolk, South is sitting there smirking. Does he disagree with that basic case?

Mr. Yeo

When the right hon. Lady responded to my previous intervention, she tried to imply that I did not know what I was talking about. She may not know this, but other hon. Members will know that, before I came here, my full-time job involved running the Spastics Society, whose major research and publicity campaigns dealt precisely with this point. That is why I have the figures in my head and why she does not.

Does she agree, as I asked her to agree before—she dodged the question—that the perinatal mortality rate is one of the most objective statistics on the measure of health in any country, and in the regions of those countries? Does she further agree that, under this Conservative Government. in the past 17 years, there has been a substantial fall in the rate throughout the UK, and particularly in London? I quoted the figures, which were kindly supplied by my hon. Friend the Member for Hertsmere (Mr. Clappison). They demonstrated that there has been an even improvement across the country.

Mrs. Beckett

I did not dispute what the hon. Gentleman said about perinatal mortality rates, because they are an important indicator. I am never in danger of forgetting that the hon. Gentleman was a director of the Spastics Society before he came to this place, because, as he will recall, I sat with him on a Committee where the Government made savage cuts in the benefits paid to people with disabilities, and I waited for him to protest on their behalf, which he failed to do.

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

I am sorry to intervene on my right hon. Friend, but, before she concedes anything on that front, may I tell her that, some years ago, I challenged those statistics in the northern region? The statistical base was rubbish, so let us be careful before we concede anything on those statistics.

Mrs. Beckett

I am most grateful to my hon. Friend. I note that, despite all that the hon. Member for Suffolk, South has said, he does not appear to be disputing either that deprivation is concentrated in London, or some of the indicators of that deprivation.

There is, of course, much more to London's health service than its hospitals. The glory of the health service in Britain, what is unique, what possibly has made it—or did make it—the most cost-effective health service in the world, has been the emphasis on primary care, in particular in relation to general practice. Unfortunately, in London that has long been an area of weakness.

In the early 1980s, reports identified some 15 per cent. of general practitioner premises as being sub-standard, but, under this Government, that problem has got worse. By the time of the Tomlinson report in 1992, 46 per cent. of general practice premises were said to be below the expected standard, yet such a development must have been foreseen. As early as 1982, the Acheson report drew attention to deficiencies in primary care in London, and to the need for those deficiencies to be addressed. Nothing happened. Not one of the report's recommendations was implemented. Thirteen years on, matters are substantially worse.

I hope that the Secretary of State will neither try our patience nor further undermine her reputation by pretending that the Government's determination to strengthen general practice has led to the attack on London's hospitals. Throughout the Government's period in office, general practice in London has deteriorated, and there is little to suggest that the current Secretary of State will do better than her predecessors.

I cite the precedent of the London Ambulance Service. Two years ago, the right hon. Lady told the House that she would be taking a close personal interest in the service's work and improvement. It is one of the few policy areas for which she has taken any responsibility, and I do not think that even she would claim that an outstanding success.

Mr. Nigel Spearing (Newham, South)

After the LAS area collapse two years ago, I sent the Secretary of State a copy of my memorandum to the Page committee. Last week, I sent the right hon. Lady the 50-page memorandum published by the Select Committee on Health, to which I gave evidence 10 days ago. Does my right hon. Friend agree that the Secretary of State should reply to my letter asking her to point out any errors of fact in my conclusions or where she differs from them? Is not the Secretary of State responsible to the House, and should she not give an undertaking to reply when she speaks today?

Mrs. Beckett

I am sure that the Secretary of State heard my hon. Friend, and that she will reply to his point. I share my hon. Friend's view that it is part of Government responsibility to deal with such matters and to respond to queries from hon. Members. After all, the Government are accountable to this place.

The Government's continuing implication that improvements in general practice, if and when they come, will lead to reduced demand for hospital beds is indefensible, as is their justification for a further massive reduction in the provision of hospitals and beds throughout London and the south-east. Beds are already being closed at breakneck speed, before investment in general practice can provide an alternative.

The pace of closures is accelerating. Between 1982 and 1990, 7,000 acute beds closed in London, but since 1990, another 3,200 beds—one in six of the 1990 figure—have closed. Since 1982, 39 per cent. of acute beds have closed in London, compared with a national average reduction of 23 per cent.

Lady Olga Maitland (Sutton and Cheam)

Will the right hon. Lady give way?

Mrs. Beckett

I will, but this may be the last time that I do so, because I am mindful of Madam Speaker's observations.

Lady Olga Maitland

In suggesting that those bed closures are a scandal, the right hon. Lady is totally misrepresenting developments in modern medicine. Does not she accept that they mean that patients can spend fewer days in hospital, creating less demand for beds?

Mrs. Beckett

Of course I accept that, but the hon. Lady will be aware of severe doubts about the pace at which beds are removed.

Lady Olga Maitland

indicated dissent.

Mrs. Beckett

It is no use the hon. Lady shaking her head. She must know the problems in London if she even looks at the Evening Standard—never mind reads it. The Government anticipated reduced demand, rather than waiting to see whether it occurred. The hon. Lady must be aware of all kinds of problems, such as patients being re-admitted after being discharged too early, and of questions about day case surgery and the anaesthetics used. It is not a simple equation of changes in medical technology enabling beds to be taken out of use. Most people in London accept that readily.

There is not a shred of evidence that improvements in general practice are forthcoming to allow a reduction in beds. There is growing belief that primary care improvement in London may reveal substantial unmet need for hospital treatment. The assumption that London has too many beds is increasingly open to question, because of long waiting lists and continuing reports of overwhelming pressure for beds. The latest report shows that psychiatric beds are at 140 per cent. occupancy, with patients sent to centres as far away as York to be treated in the private sector because there are no psychiatric, acute or secure beds available in London.

Not long ago, we were told that not one intensive care bed was available anywhere in London for an adult or a child. The London health consortium has described the pressure on the provision of beds in London. It says that if there are further bed cuts—or a bad winter which, fortunately, so far, we have not had in London—they could prompt a full-scale crisis in London's health service.

The case is open to question—never mind comparisons with capital cities elsewhere in Europe, although those cast doubt on the Government's case—because of comparisons with other cities in the United Kingdom which cast doubt even on the theoretical case for further cuts. Ministers used to argue that London and the south-east had a disproportionate share of hospitals and of beds, and used a disproportionately high amount of health service funds. Earlier studies by the King's Fund, like the Tomlinson report, seemed at first to confirm those assertions although they caused bewilderment among many who found them hard to square with the reality of London health care.

However, further work, most notably by Professor Jarman at St. Mary's hospital, which has been backed up by an even more recent study by the London health consortium, has demonstrated that if we compare like with like and city with city, it is not true that London is over-provided either with beds or with funds. In fact, the most recent figures on bed usage have Leeds, Newcastle, Manchester, Liverpool and Birmingham all above London in their use of health service beds. London has only a little above the average figure for the whole of Britain. The evidence on which the Government have relied for their changes is simply not there—quite apart from the huge and fundamental flaw at the heart of both reports to which I referred. The flaw is that they relied on the assumption that Government policies would of themselves, by the application of the internal market, remove beds from London. It was not a question of whether the beds were needed, but a question of the impact of Government policy.

The figure I quoted for the comparison between London and other cities, which shows that there is not over-provision in London, squares with the day-to-day experience of Londoners. It squares with the 168,000 people on waiting lists for the main trusts and the 6,000 people waiting for treatment in the special health authorities. The figure squares with the 140 beds that were never opened at the new Chelsea and Westminster hospital where, in the seven months from April to November last year, there was an increase of 128 per cent. in numbers on the waiting list. It squares with the threat to the existence of University College hospital when the funds of Camden and Islington health authority were slashed. The figure squares with the revelation that in Redbridge, there is no elective surgery for those waiting less than 18 months and with the fact that Redbridge waiting lists have gone up by 46 per cent. It squares too with the fact that Whittington hospital is closed for non-emergency elective surgery, with little indication about where the people whom the hospital previously served are expected to go.

Mr. Jeremy Corbyn (Islington, North)

Is my right hon. Friend aware that the restriction on non-elective surgery does not apply to the patients of fundholding GPs and private patients? They can get treatment at Whittington hospital. Does my right hon. Friend agree that that is the disgraceful two-tier health service which so many people in my constituency are expected to put up with?

Mrs. Beckett

No one could disagree with my hon. Friend's point. The position is very worrying for those who are unable to be in practices that are eligible for the Government's scheme.

The examples of deficiencies in health care that I have given all come from the time before the most recent proposal for still further changes in funding for London's health authorities. Inner and outer London together were expected to lose about £100 million in the coming year. Outer London has had some reprieve, gaining about £46 million more than expected, but £41 million of that gain has been slashed from inner London.

Health authorities in areas which rank among the most deprived in the country now stand to lose still larger sums. East London and the City, the authority in which St. Bartholomew's is situated, now stands to lose a further—almost—£14 million from its funding. Kensington, Chelsea and Westminster stands to lose almost £15 million, and Camden and Islington, which was already set to lose £27 million, will now lose more than £30 million—getting on for £31 million. Every one of those areas was already the subject of concern expressed in this House, primarily by Conservative Members on behalf of their constituents, in the debate on London health care in October.

Those new figures also show that London will receive just under 15 per cent.—14.9 or 14.8 per cent.—of the funding, despite having to cater for 15 per cent. of the population. So London is receiving an under-provision in revenue, especially when we recall the under-recording of London's population left as a legacy of the poll tax.

That brings me to perhaps the most blatant example of the chaos over which the Secretary of State reigns, which directly results from the neglect, vandalism and incompetence of Ministers. When she launched the new patients charter, the Secretary of State was pleased to boast of a new trolley standard. [Laughter.] Under previous Governments, Labour or Tory, the notion that waiting hours on a trolley in a casualty department was a standard daily expectation was inconceivable.

In January, Bart's accident and emergency department closed. The week before its closure, patients were having to wait up to 36 hours to be admitted to the alternative facilities, and some 15 patients could not be found beds because of the pressure placed on those facilities. Guy's accident and emergency department is under threat. Many patients are expected to go to St. Thomas's. But, last week, even before the closure of Guy's accident and emergency unit, patients from St. Thomas's had to be sent back to Guy's, because. there were too many to be treated at St. Thomas's.

All London has read of the child with an arrow in his eye, who spent eight hours being shuttled between hospitals before he was allowed into Bart's for emergency treatment.

Mr. Peter Bottomley (Eltham)

Will the right hon. Lady give way?

Mrs. Beckett

Was the boy with an arrow in his eye one of the hon. Gentleman's constituents?

Mr. Bottomley

indicated assent.

Mrs. Beckett

Then I shall give way.

Mr. Bottomley

The newspaper report said that a child in my constituency had been taken by air ambulance to Moorfields hospital, and that the doctors at Moorfields had been told by the paramedics that the child could not be taken to Bart's. When I checked with the local evening newspaper news desk, it said that, in fact, the child had been taken to the Royal London hospital, and that the doctors at Moorfields had not asked the London Ambulance Service whether the child should be transferred for neurological or ophthalmic treatment at Bart's. If the right hon. Lady is to read newspaper cuttings, she should check them, in the way that the constituency Member of Parliament does.

Mrs. Beckett

I do not think that the hon. Gentleman is in any way casting doubt on the point I made, which is that, right across London, there is huge pressure on casualty departments, and right across London there is strain. It is not surprising that, in such circumstances, people do not always make the correct decision—the decision that they should have made at the outset.

It does not alter the fact, whoever was at fault, that that child waited all those hours for treatment. Nor does it alter the fact that, as we heard in the previous debate, we can Produce a string of lists outlining incidents of people waiting hours on end in casualty departments right across London, of which the hon. Gentleman is perfectly aware.

In consequence, right across London and the south-east, there is fear and anger. There is anger at the loss of valuable facilities that people believe are needed, and there is real fear, especially among parents, as private surveys of opinion show, that, should their children be injured or fall seriously ill, the treatment they would need would simply not be there.

In our previous debate, the Secretary of State talked about her stewardship of our health service. Let us examine that stewardship for a moment, and look at her strategy for London and the south-east, especially for accident and emergency services.

Has there been an overall review of accident and emergency services as there has for other specialty services? No. How many hospitals in London provide such services? According to parliamentary questions, the Secretary of State does not know and, what is more, she does not think that it is any of her business.

How many accident and emergency departments are there in London and the south-east? The Secretary of State does not know, and she does not think that it is any of her business. How many accident and emergency departments are due to close in London and the south-east? The Secretary of State does not know that, either, and she does not concern herself with it. Stewardship? The Secretary of State does not know the meaning of the word.

The Government have abandoned the management, planning and co-ordination of change in London. They have abandoned their duty to those who live and work in and around the capital. The Government are always urging on us the virtues of private sector management, but no big business would act as the Secretary of State acts.

The manager of every branch of Woolworth arid McDonald's has a degree of freedom to manage the unit, but that freedom can be practised only within a well-defined and clear framework, and within guidelines laid down by the parent company. As I understand it, nothing is more precisely defined than a McDonald's hamburger.

There are varying degrees of autonomy for local business units in London's national health service, but with no strategic framework. Just imagine if the chairman of Kingfisher, the parent company of Woolworth, was asked how many Woolworth branches there were in London, and he had to reply that that information was not centrally held, which is the Secretary of State's stock reply.

Imagine that McDonald's was restructuring its business and downsizing its operation, and, when the shareholders asked how many branches were going to close, the chairman said, "This information is not held centrally."

A whole new vocabulary is developing. "Rationalisation" means—

Mr. Nigel Forman (Carshalton and Wallington)

Will the right hon. Lady give way?

Mrs. Beckett

No: I have almost finished.

"Rationalisation" means closure. "Information not centrally held" means "I haven't got a clue", and instead of decisions we have strategic directions. We have a strategic direction for the Secretary of State: the exit is that way, and she can rationalise the door behind her as she goes.

Mr. Forman

Will the right hon. Lady give way now?

Mrs. Beckett

I have almost finished, and I am mindful of Madam Speaker's observations.

Imagine if ICI had just invested in a new state-of-the-art building, the most modern in the industry, which had cost £150 million and had taken eight years to build. However, before it was even occupied, the chairman decided that the facilities would never be used by that part of the business for which it was intended. Just imagine what the shareholders of the company would say to such a cavalier and irresponsible treatment of their funds.

However, that is exactly what will happen to Philip Harris house at Guy's hospital, which the Secretary of State has decided will never be used for the service that it was intended to provide. That is typical of the Government's cavalier attitude to the use of public and private funds.

In London and the south-east today, there is no strategic planning, no overall investment strategy and little consideration of whether a wider national or public interest should materially affect decisions locally made. There must be a moratorium on further bed closures, in case they have already gone too far.

In the breathing space that such a moratorium creates, there must be a fresh and thorough assessment of the needs of health care in London, of needs driven by medical technology, which was the case made by the hon. Member for Sutton and Cheam (Lady Olga Maitland), and of the needs of elderly and frail people, particularly where, as in London, there is such a lack of alternative places. There must be an assessment of those needs, and further consideration of how those needs are to be met.

By no definition, and by no standard, can the Secretary of State's attitude to health care in London and the south-east be called stewardship. The Government are not stewards, because that word implies duty, responsibility and care. The Government are just incumbents, and the sooner they cease to be so, the better for London, the better for the south-east, and the better for Britain.

4.3 pm

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

I beg to move, to leave out from "House" to the end of the Question and to add instead thereof: 'recognises that, because of medical advance, shifts in the population and the changing needs of patients, reform of the health service in London is both necessary and long overdue; congratulates Her Majesty's Government for its resolve in addressing the modern needs of people in the capital and the South East, in sharp contrast to the vacillation and evasion of the Opposition; and believes that policies now being pursued have already delivered a better health service for the area, enhancing the excellence of research, teaching and treatment as well as improving local health services in the parts of greatest need.'. I welcome this opportunity to describe the progress being made to modernise London's health service. We are improving the quality and responsiveness of hospital services. We are investing in primary care and we are enhancing the capital's status as an international centre of clinical teaching and research. I shall be announcing more money for primary care. I shall tell the House of important new developments around some of the hospitals and medical colleges in London and important changes taking us nearer to the heart of our vision of four world-class hospital complexes clustered around multi-faculty universities and colleges.

I congratulate the right hon. Member for Derby, South (Mrs. Beckett) on being here to open the debate. The last time Labour Front-Bench Members chose to debate health in London, their health spokesman did not even turn up. Instead, their transport spokesman came along, mouthed a few sound bites in advance of impending local elections and sat down. He said nothing about Labour policy. That showed the real face of the Labour party: it is interested not in serious health issues but only in party politics and partisan advantage.

I give credit to the right hon. Member for Derby, South. She suffered widespread criticism of her Trappist approach to Labour health policy. With some justice, The Lancet recently asked: What would a Labour government do with the NHS? With some justice, it gave the answer: It's no use asking the Party's spokeswoman on health; she refuses to say". However, the right hon. Lady has now produced a plank of policy. Unfortunately, it is the wrong policy, but we cannot have everything. She wants a moratorium on bed closures in London. She wants, as her motion states, a fresh and thorough review". There have been about 20 fresh and thorough reviews in the past 80 years, and they have all said the same thing: we need movement and improvement, not a moratorium. London needs action and change, not yet another review.

Labour Members have cut themselves off from what has to be done. They have ignored even the advice of The Guardian, which stated: A party preparing for Government should resist the easy option—opposing all hospital closures—and concentrate on filling out its own plans. Rarely can a party have so wallowed in the irresponsibility of opposition. Labour Members' dithering in opposition shows why Labour would be such a disaster in government.

I should say at the outset that I cannot comment in detail on the proposals around St. Bart's, the Royal London, or Guy's-St. Thomas's. They are or have been the subject of statutory public consultation and as Secretary of State I am in a quasi-judicial position in relation to the proposals which are likely to come to Ministers for final decision.

Mr. Brian Sedgemore (Hackney, South and Shoreditch)

The consultation period on whether Bart's is to close ends tomorrow. Yet in yesterday's edition of The Sunday Telegraph there was a quotation from a letter from the Secretary of State for Employment saying that the decision to close Bart's had not been taken lightly by the Prime Minister and by the Government. What is the point of consultation when decisions have been taken before 6 February and consultation is continuing until 21 February?

Mrs. Bottomley

I am grateful to the hon. Gentleman for giving me the opportunity to make it clear that the matter is subject to open consultation. I am sorry that there should have been any misunderstanding at all. I am sure that the hon. Gentleman and his constituents, and my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke), will be extremely pleased to hear that.

The hon. Gentleman will be aware that on the previous matter there was a great effort to take the issue to judicial review. That challenge was totally and utterly rebutted. In all matters, Ministers have behaved with absolute propriety and will take forward the consultation in the proper way. I am delighted to make that absolutely clear.

These are serious matters affecting not only London and Londoners but people throughout the country. I should like to set out again the underlying issues facing those and all the great hospitals in London. They are the same issues which face the south-east and the rest of the country. The issues are linked: what we do in London affects what can be done outside London. The London health service is part of a national health service.

The service in London faces many difficult challenges. One of the reasons why we began the process with Tomlinson was precisely to address those problems head-on. To duck out now would blight the capital's health service for at least a generation. The Labour party's shoddy analysis of London's needs and problems will not do. The fundamental issues, none of which the right hon. Member for Derby, South addressed, result from changes in where people live, changes in how they choose to be cared for, and the need to adapt to the evolving potential of modern medicine.

Within a six-mile radius of this place there are about 22 major acute hospitals. That cannot be said of any other part of the country. That concentration of hospitals grew up mainly in the previous century to meet national rather than specifically London needs, let alone the day-to-day needs of local communities. The population has moved away. London's population has fallen dramatically by about 1.3 million in the past three decades. People who used to come to inner London hospitals from all over the south-east and beyond are now turning to their own hospitals for care.

Lady Olga Maitland

My right hon. Friend refers to the reluctance of patients to come to London. Is she aware that patients in my constituency in Sutton can now go to the St. Helier's national health trust hospital, which provides all the services they need?

Mrs. Bottomley

A generation ago, people travelled from the home counties to the London hospitals, but there has been a massive development of services throughout the home counties. Patients and GPs rightly say that they would rather have treatment close to home than travel to London. That is precisely what is causing great difficulties for the London hospitals, which have fixed overheads.

Mr. John Austin-Walker (Woolwich)

Does that square with the Secretary of State's decision to transfer further into London the regional neurosciences units and the cardiothoracic units based at the Brook hospital in Greenwich, which serve the Kent area?

Mrs. Bottomley

I shall be emphasising at some length later in my speech the crucial importance of academic excellence and research. London has been a capital city for medical research and teaching, and there is duplication and fragmentation of centres. If we wish to be a world capital for medicine in the next century, we must concentrate on centres of excellence.

We undertook an unprecedented review of the specialty services, in which about 200 clinicians were involved. The prime position given to the Institute of Psychiatry and the campus at Denmark Hill, and the contribution which could be made to international research and teaching by the integration of the neurosciences centre from the Brook hospital were decisive factors in our supporting the recommendation. It is precisely that commitment to excellence that has driven the framework within which the changes have been seen.

Mr. Hugh Dykes (Harrow, East)

I am sorry that I was late for my right hon. Friend's opening remarks. She rightly referred to the growing importance of a comprehensive range of services in outer London and in the home counties. Does she agree that it is vital to keep open— in all and in part— the services of Edgware general hospital in the future?

Mrs. Bottomley

My hon. Friend—like almost every constituency Member of Parliament—has a great affection for his local hospital, the way in which it has evolved over the years and the service that it provides for the local community. The dilemma that we face— which any responsible Government would face— is that report after report has argued that if we want clinical excellence we must look towards the consolidation of services. For example, at the Royal London we can have a 24-hour consultant-led accident and emergency department.

A couple of weeks ago, a major report from the clinical standards advisory group argued again about the quality that we should be looking for in an accident and emergency department. We can deliver that quality, commitment and back-up in terms of staff only if units come together. A balanced judgment must be taken on the pace at which we move towards those centres.

Another example is cancer services. The Chief Medical Officer's report on cancer services argues for a concentration of centres with a relevant critical mass, which always leads to difficult decisions for individual Members of Parliament.

I say openly to the House that if we want to have the quality of services advanced by the royal colleges and by virtually every expert report, we must see how we can address the issue of hon. Members' great affection for their local hospitals which cannot provide the critical mass, the sub-specialties and the costly equipment that we need for state of the art services.

Mr. Dykes

On a point of order, Madam Speaker. In view of the unsatisfactory nature of that reply, I beg leave to give notice that, with your permission, I shall seek to raise the matter on the Adjournment.

Madam Speaker

I have noted what the hon. Gentleman has said, but as the motion is not a substantive one he should not have interrupted at this stage. He must seek an Adjournment debate and take his chance.

Mrs. Bottomley

I used my hon. Friend's particular example to make a more general point which any responsible holder of my office has to take into account when looking at the interface between a series of expert reports and the understandable and strong views of constituency Members of Parliament.

Several hon. Members

rose—

Mrs. Bottomley

I should make headway. The point is well made. The constituency points made by my hon. Friend are subject to consideration. Decisions have not been made. I was using the example to make a more general point.

Not only do we have hospitals around London. As my hon. Friend the Member for Sutton and Cheam (Lady Olga Maitland) said when she gave an example from her constituency, some patients who are treated in London would prefer to be treated closer to home. An example is the new cardiac unit being built in Plymouth to treat, among others, patients who currently come 250 miles to the Royal Hospitals trust. A new £5 million cardiothoracic centre is being established in Brighton. There are two major new oncology centres, in Maidstone and, as my own constituents know well—

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

Ah.

Mrs. Bottomley

—in Guildford, where £12 million is being spent upgrading and relocating cancer services.

That is the modern health service taking root. History has left a proliferation of small specialist units within a few miles of each other in central London. Before the hon. Member for Workington (Mr. Campbell-Savours) gets too carried away, he will want to know that in my constituency I have faced precisely the changes that I have described in relation to my hon. Friend the Member for Harrow, East. My own hospitals are becoming community hospitals because we have a concentration of speciality services outside my constituency, in Guildford. I hope that the hon. Gentleman understands that.

Those small units, often within a few miles of each other, are run by skilled clinicians. In these days of modern medicine and high technology, it cannot make sense for the speciality reviews to find 10 radiotherapy units, 13 cardiac surgery departments and 11 renal dialysis centres all in such close proximity. The simple fact is that it is impossible to sustain the highest quality care in so many fragmented centres. The talent and expertise of the clinicians, and the money available to purchase equipment, is too thinly spread.

As I have made clear, the number of patients referred to London for specialist treatment will fall. As it does, it will become ever more difficult to maintain the quality of services in each centre. The royal college training accreditation is in jeopardy in neurosciences and other specialities at Bart's because the number of patients that it treats is now below the clinically recommended levels.

For example—this, again, is an issue for my hon. Friend the Member for Harrow, East (Mr. Dykes)—Professor Sir Norman Browse, the president of the Royal College of Surgeons, has said: To maintain and improve professional standards, we have to amalgamate the remaining in-patient beds so that they achieve the critical mass necessary to provide the experience needed to train and educate junior doctors and maintain the consultants' expertise. Time and again, expert o and independent speciality reviews have argued that for better patient care we must have specialist services concentrated in fewer, larger centres, so as to make better use of finite resources and dedicated staff.

Modern clinical equipment is expensive. A computerised tomography scanner can cost £500,000. A magnetic resonance imager can cost £1.5 million. By clustering hospitals, we can ensure the best use of these medical miracles, which were not even conceived when the NHS began in 1948, let alone when most of London's hospitals were constructed in the last century.

We can make better use of our doctors, with their highly specialised and scarce skills. We are committed to reducing junior doctors' hours. My hon. Friend the Minister is meeting them this week to discuss the issue further. Smaller units needing 24-hour cover require junior doctors to be on site all the time. With fewer larger centres, the load can be spread. We can achieve the ambition both of the Government and doctors to improve the quality of life for medical professionals.

There is another reason why we need fewer, better centres. Fragmenting services across so many sites makes it much more difficult to manage beds. We frequently hear about the pressure on beds for emergency admissions and I do not discount the problem. A recent comprehensive study in London, carried out by the inner London health authorities, dealt with that important issue and I commend it to the House. Copies are easily available in the Library and, I believe, in the Vote Office.

The report states: Larger hospitals and those with larger pools of beds were found to be better able to manage variations in demand for admission. Those with a lower proportion of emergency admissions could operate at higher occupancy levels. The report concludes: Better clinical and management systems than in the past need to be in place if such problems are to be handled without detriment to quality of care or the planned admission of non-urgent patients. In a significant passage, it states: It was thought that extra acute beds would not solve those problems in a cost-effective way. They are better addressed by the management of admissions and discharges in collaboration with all the parties involved. The Government have set out the strategic direction for the health service in London, which that important report endorses.

Mr. Peter Shore (Bethnal Green and Stepney)

On the important question of concentration of facilities in one spot, obviously there is an argument for larger and fewer units and we are familiar with it—it applies to many things other than the health service or hospital services—but there are disbenefits and additional costs from highly concentrated organisations.

The London hospital is to be concentrated on the Whitechapel site, with the closure of the London Chest hospital, part of Bart's and the Queen Elizabeth hospital. A huge and costly investment programme will be necessary on the Whitechapel site to provide facilities which one hopes will be similar and equal to those to be closed. Is there any guarantee that the money will be made available within the time scale involved?

Mrs. Bottomley

Obviously, those matters are all subject to the consultation, on which I cannot comment at the moment. If the right hon. Gentleman has read the document, he will know that, out of something like a £95 million cost for the status quo, much of the capital cost will be used to refurbish the existing facilities. The document suggests that there will be revenue savings of £22 million a year as a result of concentration on one site.

The right hon. Gentleman will be aware that academics and researchers feel strongly about the great opportunity to bring together research teams; with a larger group, they can have sub-specialties and all the opportunities of mixing disciplines. Academics, with whom I spend an enormous amount of time, are concerned that if we allow the fragmentation of the small centres to continue it will be almost impossible to build up the substantial clinical and research teams with which they hope to pioneer innovations.

Mr. Forman

I am mindful of my right hon. Friend's argument about the benefits for academics of an inter-disciplinary approach in large clusters of hospitals, and it obviously makes sense. But is she aware of another argument, which tends to point the other way—the possibility of diseconomies of scale on the managerial side if the management of those vast enterprises are expected to manage something many times larger than the units that they were managing?

Mrs. Bottomley

I accept my hon. Friend's argument, but the hospitals that we are discussing are relatively modest in size compared, for example, with some of the most internationally famous hospitals in the United States.

I regard Boston as a competitor with London in terms of the prime position in medical research and teaching. It was interesting for me to meet the professor in charge of Massachusetts university hospital recently as he was amalgamating a 1,000-bed hospital and an 800-bed hospital. The changes that we are making in London are being made in Boston, Sydney, Paris and virtually every capital city in the world. Those changes matter so much partly because Londoners deserve a better health service. As the right hon. Member for Bethnal Green and Stepney (Mr. Shore) may know, my first job was in Bethnal Green, so I know only too well how inadequate and paltry the community and family doctor services were for people in that area. However, I am also strongly committed to our international position and centres of excellence. It is no coincidence that our university hospitals of Oxford and Cambridge, in areas where there is no fragmentation or duplication, find things much easier than some London centres precisely because those are so numerous.

It would be wrong to delay matters, have a moratorium, and abandon the process of change because that would put everyone in limbo and a state of uncertainty. People in London want to know what the future holds and to build for the next century.

Sir John Gorst (Hendon, North)

Will my right hon. Friend help me by reconciling her logic and information with the illogical feelings of my constituents, who are unanimously against her proposals? Have I any alternative but to represent their views in the Lobby, contrary to how my right hon. Friend would wish?

Mrs. Bottomley

I repeat what I said to another hon. Friend: a balance must be struck between the move towards clinical excellence, the concentration of services, better services, the issue of junior doctors' hours, and the pace at which change can be achieved. Issues concerning my hon. Friend's hospital are being carefully addressed. I totally accept that every hon. Member must balance local wishes, which are nearly always to avoid change—the populism that we have seen from the Opposition today—and a more principled approach which believes that if we want clinical excellence for the future we must face and take difficult decisions.

Sir John Gorst

Without my vote, then.

Mrs. Bottomley

I hope that my hon. Friend will discuss those matters further.

Mr. Corbyn

Will the Secretary of State give way?

Mrs. Bottomley

No. Many hon. Members wish to speak in the debate.

We need to invest in the acute sector and more must be done to improve infrastructure in London. We are backing our commitment with a substantial amount of cash: £28 million for redevelopment of the Lewisham hospital; nearly £20 million to develop the Homerton as a full district general hospital serving the people of Hackney; nearly £15 million for the London ambulance service—

Mr. Spearing

Will the Secretary of State give way?

Mrs. Bottomley

I heard the hon. Gentleman's intervention in the speech of the right hon. Member for Derby, South and I shall consider it carefully. I greatly appreciated our lengthy and informative discussion on the subject earlier in the year.

We are spending more than £8 million to upgrade and expand the accident and emergency department at King's—

Mr. Spearing

Will the Secretary of State give way?

Mrs. Bottomley

No, but I look forward to reading the hon. Gentleman's speech in Hansard later.

We are spending £3.2 million on the St. Thomas's accident and emergency department; £2 million for the Whittington; and nearly £2 million at the Royal London. [Interruption.] Opposition Members do not want to hear that list of investments and would rather drown it out, so substantial and significant is our record of investment in the London health service.

The list goes on and on, but the key issue is that it is investment in the future, not in the past, and it is close to where people live. We should not continue to sustain the current revenue cost of £70 million a year in duplication and fragmentation of an outdated pattern of hospital care. To do so would be unfair to the taxpayer, to other parts of the south-east and the rest of the country and to London when money should be targeted on basic health services in the community, which are so badly needed.

We have come to terms with the paradox that clinical developments point to a need for fewer acute beds. It is a paradox, and I understand hon. Members' concerns, but we see the development of day surgery, minimally invasive surgery, new drugs and other medical advances. All of those mean that we can treat more patients in fewer acute beds.

Because of those developments, the number of beds has been falling in the UK and elsewhere for the past 30 years. But fewer beds do not mean fewer services. There has been a massive expansion in the number of patients treated, reductions in waiting times and a transformation in the range and sophistication of treatment available. In the past year, the number of people waiting more than a year for treatment in the Thames regions has fallen by 7 per cent. In a five-year period from 1988, the number of hip replacement operations increased by 2,500. During the same time, there was a fourfold increase in the number of liver transplants. The Labour party should know that it is simplistic just to look at the number of acute beds. We must consider how they are used and what that tells us about the balance between acute and non-acute beds and services generally.

The inner London health authorities' report concluded that the use of acute hospital beds is significantly above the national average. But there is no evidence to suggest that, on average, Londoners need to go into hospital more than people living elsewhere in the country. What the figures reveal is that the wrong beds are being used in the wrong way. Patients—particularly elderly patients—are being kept in hospital longer than they need be when they could better be discharged to proper care outside hospital, which is better for patients and for the NHS. For some, that will mean a nursing home. Evidence shows that, since our community care reforms, the number of nursing home places in London has begun to rise—200 more this year, but 1,800 more in the pipeline. That is a substantial increase in the number of nursing places for older people.

Local authorities have been well funded to meet their new community care responsibilities. This year, the London boroughs have received a total of £850 million for community care—more than one fifth more than in 1993–94. The funds available will rise by a further £95 million for 1995–96. The London boroughs are well placed to support a continued growth in nursing and residential facilities outside hospital. We look to them to discharge that stewardship in a responsible manner. As Professor Jarman has pointed out, we need more "low-tech" beds, as he calls them. It is because of the Government's reforms and the money that we have put back into them that the expansion in services is at last becoming a reality.

The right hon. Member for Derby, South referred to primary care. Sadly, primary care in London has lagged behind other parts of the country, but it would be quite wrong not to draw her attention to the very substantial improvements that have been made since the Acheson report. Of the 31 main recommendations of the report in 1981, 26 were implemented within 10 years. Between 1978–91, the number of general practitioners in London increased by a further 310 from 3,523 to 3,833. Many other recommendations were implemented: the retirement age for GPs; higher payments in underprivileged areas; standards for the reimbursement of rent of surgeries; screening for people over 75; and the co-ordination, by community health experts, of district health authority services for children. The right hon. Lady would be quite wrong to fail to recognise the dramatic changes that have been under way, but there is clearly a need to do even more.

Over the past two years, we have already invested an additional £125 million in primary care, which is creating and supporting more than 1,000 projects in London's areas of greatest need. A transformation is under way. There are more than three times the number of practice nurses as five years ago. The GP contract, introduced in the face of bitter opposition from the Labour party, has brought an increase in child immunisation and cancer screening, of which my hon. Friends are so proud. Above all, the GP contract brought in extra payments for family doctors working in deprived areas. What hypocrisy it is for the Labour party to lecture us about poverty and ill health when it opposed that measure in the House.

Despite those achievements, however, there is more to be done. I am pleased to be able to announce that we shall be investing a further £85 million in primary care initiatives in London's most needy areas in 1995–96. That is a substantial sum. I know that my hon. Friends who represent areas outside London want it to be wisely and well spent, but it will enable us to implement our key objectives—to improve GP practices and other primary care premises; to increase the range of services that GPs can offer their patients; and to assist the development of health teams working in the community. It will include an investment of £20 million over two years in a new education programme for London GPs.

Ms Glenda Jackson (Hampstead and Highgate)

Will the Secretary of State give way?

Mrs. Bottomley

I do not intend to give way again. I have already given way many times, and I know that my hon. Friends are keen to speak. I am normally rebuked for giving way too much, so I hope that the House will bear with me.

Mr. Corbyn

On a point of order, Mr. Deputy Speaker. We rarely engage in debates on London's health. If the Secretary of State is not prepared to give way, how on earth can we use our one opportunity to question her directly about matters of deep concern to all hon. Members?

Mr. Deputy Speaker (Mr. Geoffrey Lofthouse)

I said from the Chair the other day that I had long waited to hear a genuine point of order. I also said that it was very unlikely that I would do so in the near future, but that I lived in hope. I am not very satisfied with what I have heard today.

Mrs. Bottomley

I am between the devil and the deep blue sea, Mr. Deputy Speaker. I should make it clear that I regard the Chair as the deep blue sea and the Opposition—otherwise. Madam Speaker often severely rebukes Front Benchers for speaking at great length. I realise that I have already spoken for longer than the right hon. Member for Derby, South, although I think that I have given way more times than she did, but we shall consult the record tomorrow.

The issues involved are enormously important. We want to introduce improved training programmes to attract and retain high quality family doctors, and to improve opportunities for GPs to maintain high standards where they are needed most. We are also considering further steps to help, in particular, smaller practices to recruit and retain practitioners and assistants. We want more and better GPs, providing better services; we want in London family doctor facilities and community teams of the range and quality that are already common elsewhere. We want more of the fundholders who have been the pioneers of change in primary care. I am pleased to say that we expect London and the south-east to match the rest of the country by April, with some 40 per cent. of its population covered by fundholders.

I also welcome the prospect of GPs forming groups to purchase services for their patients, and the news that Professor Jarman and others are to join the central London multi-fund.

We are targeting people with specific needs—the elderly, the homeless and people with mental health problems. In the current year, £10 million of additional money is being invested in better services for the mentally ill in London. I can also announce that at least the same amount will be available again in the coming year for the special needs of people with mental illnesses. A vast range of programmes is now in place around the capital to improve care in the community for mentally ill people.

There are schemes such as that run by the Hackney Sanctuary, which provides crisis support to help avoid the admission of patients to acute hospital beds, and there is a new residential scheme in Camden and Islington. There are other schemes in Hounslow, Lambeth, Hammersmith, Greenwich, Haringey and Croydon; throughout London there has been rapid investment in practical schemes to help those with mental illness cope in the community. Time and again, Opposition Members re-emphasise their commitment to the principles of care in the community; I ask them to recognise all that is being achieved, and to acknowledge that more will be done because of the extra money that the Government are committing.

I feel that, as we are discussing important and serious issues, I should set out. what is happening, what has been achieved and the issues that remain to be tackled. My hon. Friend the Member for Carshalton and Wallington (Mr. Forman) referred to the importance of education and research. Those are fundamental to the reputation of London as a world leader in medical teaching and research. Bringing the different specialist centres together in the way that I have already described is difficult, but it is a vital part of securing the long-term objective.

The synergies which consolidation brings will help research thrive. Formal academic integration of pre-clinical medical education with the basic science faculties of the university of London will enhance the range of options for students, researchers and clinicians. [Interruption.] It is noteworthy that the Opposition greet with mirth and merriment issues that for many years have concerned Lord Flowers, Lord Annan and the vice-chancellor of London university. People feel deeply about these issues and they should be given proper priority as the changes take place.

We are working towards our vision which is based on four world-class hospital complexes clustered around four world-class colleges. The multi-faculty colleges will provide the engine room of basic science. This will be carried through in their associated medical schools and hospitals into clinical science and clinical research. It will allow the benefits, for example, of new advances in molecular biology and genetics—advances pioneered in this country—to have practical results in the care of patients.

We are making strong progress. All undergraduate medical schools proposed for merger are now committed to merge and are making plans to bring this about. The Institute of Psychiatry, associated with the Maudsley hospital, has entered into a formal association with King's college. A private Bill to enable the merger of King's college with the united medical and dental school of Guy's and St. Thomas's is currently passing through another place.

The Maudsley is the world's pre-eminent research institution of its type. People are already coming from all over the world to work there because of the great opportunities that it offers. Imperial college recently announced agreement by the Charing Cross and Westminster medical schools, the National Heart and Lung Institute and the Royal Postgraduate Medical School to merge with Imperial and the St. Mary's medical school to form a new Imperial medical school. The new school will make a significant contribution to both undergraduate and postgraduate education and to research. It will contain several teams of the highest international standing. These proposals will forge a brilliant alliance between some of our top clinical researchers and Imperial's scientific and engineering excellence.

The merged college will be focused on a new basic and life sciences building to be built at Imperial's Kensington site. The financial case is still being examined by the Higher Education Funding Council. However, I can announce to the House that I am prepared in principle to commit a substantial capital contribution to the scheme. As a result of this work, and the money with which the Government are prepared to back it, the new school should be admitting its first students in the autumn of 1998.

Our policies are also working to underpin the international reputation and excellence of University college hospital. It is making good progress in its association with the institutions based in Queen's square and has recently completed a financial case for the development of the Gower street site. This proposal has strong support from the academic and clinical community. I hope that formal consultation on the resulting service changes will begin before Easter.

I also commend to the House the private Bill which would enable the merger of Queen Mary Westfield college with Bart's and the London hospital medical colleges. These multi-faculty colleges with their clusters of hospitals in London will be ideally placed to take forward the highest calibre medical education and research. The critical mass of expertise within each centre will allow the widespread dissemination of best clinical practice.

Mr. Jim Dowd (Lewisham, West)

On a point of order, Mr. Deputy Speaker. The Secretary of State has been speaking for 40 minutes. I accept that she has taken a number of interventions, but in the spirit of Jopling—

Mr. Deputy Speaker

Order. That is not a point of order and the hon. Gentleman knows it. This is a limited debate and many hon. Members wish to take part. Interventions of that nature do not help.

Mrs. Bottomley

I am coming to the end of my speech, but it would be wrong for the House not to be aware of how much is happening in terms of the investment in primary care and mental health services and how vital is the consolidation of medical research and teaching if we are to take pride in our national health service for the century ahead.

The Government will not shy away from what must be done. We utterly reject the Opposition's vacillation and evasion. We will have no truck with their moratoriums, their counsels of delay. We reject their plans for a health service run by councillors, which would inflict on our hospitals the same unholy alliance of bureaucrats and councillors as we saw in the Greater London council, which left thousands of Londoners isolated in inner London despair. As The Economist said: The choice, after all, lies between preserving Victorian glories and providing better health care for Londoners. London deserves a health service that is fit for the 21st century. Much hard-fought ground has been won, momentum has been generated and much has been achieved. We wish to carry the services forward, accept the change and bring an end to uncertainty in the interests of medical research, staff and patients in London and throughout the country.

4.45 pm

Ms Tessa Jowell (Dulwich)

I tried about half a dozen times during the Secretary of State's speech to ask questions, but I regret that she did not give me or a number of my hon. Friends the opportunity to intervene.

On Saturday night, I visited five accident and emergency departments; it is in those departments that pressures are most felt, because of lack of beds. I visited King's College hospital, which is used by most of my constituents, Homerton hospital in Hackney, North Middlesex hospital, Chase Farm and the Whittington, which is my local hospital. Each one except the Whittington was having what was described as its quietest night for weeks. As one sister put it, "Usually by now patients and trolleys are everywhere, coming out of the woodwork. It is chaos."

Each hospital had free beds. For example, the Homerton had 10 beds when I arrived but during the 45 minutes of my visit, five were filled. I was told by one of the sisters, "On a night like this, we do a little better than just cope." That is what is happening on an easy night in London's accident and emergency departments. In every hospital, the staff thought that they were having an easy time if they had any free beds at all. In each hospital, the circumstances of the past 12 weeks were described as barely tolerable for staff or patients.

On 24 January, at King's College hospital, there were 19 trolleys, each with a patient waiting for a bed to become free. On 6 February, also at King's, there were 15 patients waiting on trolleys. At the Homerton two weeks ago, 26 people could not be found beds and at the Whittington the weekend before last, an extra 37 beds had to be put up. During my visit, the staff thought that they were having a quiet night because the pressure was off, but only one of the hospitals had an occupancy of less than 98 per cent. The inner London chief executives' report, to which the Secretary of State referred, accepts that that is too high and that hospitals should aim for a bed occupancy of 85 per cent. if they are to deal with the fluctuations of demand. Ministers believe that better bed management will be the solution to the bed crisis.

One of the reports that accompanied the inner London chief executives' report made plain what passes at the moment for a bed management strategy. The report states: In most cases action is taken as occupancy approaches the hospital's 'danger' level". It refers to the early discharge of patients by consultant led ward rounds…Clearance ward rounds were a common feature of hospital life … The cancellation of elective admissions or the restriction of elected work to urgent cases only … Use of the EBS system that is, the emergency bed system to restrict the hospital to its catchment area or to medically refereed cases". I have the latest figures for the emergency bed system, which show a 100 per cent. increase in the number of patients admitted as a result of being medically refereed for the month of January— the intolerably pressurised month referred to by so many of those to whom I spoke on Saturday.

The report continues: Treat and transfer arrangements were not a common response. Experience suggested that in times of bed shortages other hospitals were generally unable to provide cover. The report says that mixed-sex wards, and even mixed-sex bays, are now common. It points out that the transfer of patients between wards and, in some cases, between sites make compliance with the patients charter named nurse standard difficult. It also says: Putting up extra beds and the opening of closed wards and bays at very short notice were reported by most inner London Trusts There was also the Use of day or 5 day surgery wards for medical emergencies". That is how hospitals are getting by; they are just coping day by day.

At the same time, the Secretary of State has introduced a new patients charter standard—70 per cent. of trolley waits to be admitted within 90 minutes of the decision to admit. Another patients charter standard about to be implemented is that of choice—for elective patients to choose to come into hospital to a mixed-sex ward, or to choose not to come into hospital if the only bed available is in a mixed-sex ward or mixed-sex bay.

What the Secretary of State will not do is accept responsibility. She sets those standards but then walks away from them. She says that it is all the responsibility of the purchaser, while taking even more money away from the purchasers, whose hospitals have to resort to trolleys and mixed-sex wards only because the right hon. Lady will not fund them to open the beds that her cuts have forced them to close.

The pressure is not just on acute beds hut, as was recently reported, on intensive care beds—and with tragic consequences. Out of the hospitals that I visited on Saturday, on a quiet night, only two intensive care beds were available.

All this has resulted in another sort of folly. I shall cite a specific instance of the problem being encountered by one of my constituents, who is a consultant at Bart's. For the past two weeks he has been trying to operate on a 75-year-old woman who has a desperately serious form of cancer. She has been in hospital for three weeks being prepared for major surgery. The first time her operation was cancelled was just an hour before it was due to take place, because the intensive care bed that had been booked for her had been taken by another patient. Exactly the same happened again last week and there are now real fears that her condition will begin to deteriorate.

The problem is that there are four high-dependency beds at Bart's that have never been opened, thus requiring intensive-care beds to be used when patients could be better and more appropriately nursed in high-dependency beds. That sort of folly is putting patients' well-being at risk and sabotaging the best efforts of dedicated staff.

Mr. Spearing

I am grateful to my hon. Friend for giving way, unlike other hon. Members on occasions. Does she agree that the nub of the matter is the responsibility of the Secretary of State? Can my hon. Friend suggest any reason why evidence given to a Select Committee on the serious matter of the London ambulance service should not, after examination by the Secretary of State, be the subject of a reply from her to any hon. Member pointing out points of logic and matters of fact? The Secretary of State has a responsibility to do that and she should have said so during her speech.

Ms Jowell

My hon. Friend has made an important point. What causes us so much frustration, and what causes so much frustration and anger throughout London, is the extent to which the Secretary of State appears to have abdicated all responsibility for the chaos that she has created.

Every night, the folly of Ministers in refusing to accept the evidence is played out in the suffering of patients and the shattered morale of exhausted staff. All are victims of a Secretary of State who prefers to believe her own fairy-tale view of the world rather than confront the reality that she has created.

Florence Nightingale gave her name to the organisation of wards with beds in long straight lines—something that persists in some of our hospitals today. The Secretary of State has given her name to another sort of ward—the Bottomley ward, where patients on trolleys are lined up in corridors waiting for beds to become free.

What is also clear, and what was made patently clear to me during my visits on Saturday night, is that the confidence of both patients and staff has collapsed. So much for the primary-care-led national health service. Patients are voting with their feet. The loss of confidence among them means that instead of going to their general practitioners and facing what they know will he a long wait before a hospital appointment is offered, they short circuit that delay and go to the accident and emergency departments because they believe that that is the only way that they can be guaranteed seeing a doctor.

There is also evidence that 999 ambulance calls are not always appropriate, but again it is for the very reason that people have no confidence that if they go to their doctor they will be referred to hospital before their condition becomes worse. They believe that the only sure way of getting into hospital is to phone for an ambulance to take them there.

There also seems to be evidence of a loss of confidence among general practitioners, which is shown by the increasing tendency to make an immediate decision to refer a patient to hospital. A few years ago, doctors might have kept patients under review for hours or days. However, they now know that their patients will have to wait, so they feel that it is better to get them on the list early.

What is so dreadful about all this is that it is a direct result of ministerial action. The Government have gambled on the possibility that improved primary care will reduce the need for hospital beds. There is no evidence that that is the case; indeed, the contrary appears to be true. They have gambled on the belief that more work will be done on a day-care basis, thus reducing the need for in-patient beds. In fact, all the evidence shows that premature discharge after a day's surgery results in a rise in the rate of readmissions. The cynics would say that that might not be very good for the patients, but it increases the number of finished consultant episodes. That number goes up every time a patient walks through the door.

Hospital beds are being closed before the alternatives have been properly developed and their effectiveness tested in practice. It is a chaos of the Government's making, even on a quiet night in accident and emergency departments in London. As one sister put it: You want to do your best for patients but you can't, the pressure is too great, sometimes you cannot even get a patient a drink. We did not train as nurses only to be able to put sick people on trolleys. If the Secretary of State continues to refuse to listen to the voice of the Opposition, or to the evidence that confronts her every day, perhaps she will consider the evidence in a report she commissioned from inner London chief executives. It said: On the basis of the evidence presented to us there are reasons for anxiety about the ability of the system to cope with a further round of bed closures without action to improve throughput and particularly arrangements for the care of the elderly. I offer the Secretary of State another piece of advice. It comes from Robert Maxwell, in a press release about a report to be published by the King's Fund on Wednesday. He says: The pacing and sequence of change must take top priority. Because there is so little margin for error, there should be no reduction in services—whether for those with acute conditions, for continuing care of elderly people, or for those with mental health problems—until alternatives are in place. Accident and Emergency departments should not be closed until other ways of dealing with their work load are secure. That simply is what we are asking for. We are asking the Secretary of State to accept the advice provided by her own inner London purchasers, and to open the beds that she has closed to relieve the intolerable pressure on the patients of London.

4.59 pm

Mr. Roger Sims (Chislehurst)

The motion invites us to recognise the Government's failure either to assess the health care needs of the area properly or to plan a programme by which those needs can be met". I suggest that, in her speech, my right hon. Friend the Secretary of State for Health effectively refuted both those contentions. The facts and figures that she produced showed that needs have been assessed and that plans have been put in hand to meet them. The assertions in the motion are not true in the part of south-east London with which I am especially familiar—my constituency Bromley. What is happening in Bromley is not unique.

The health authority and family health services authority in Bromley have been working as one for several years, chaired by a very able lady and a most effective board of directors—which include a prominent local member of the Labour party—and run by a professional and energetic chief executive. Bromley health authority has assessed the needs of the local community and it has planned and begun to execute a programme to meet those needs.

Bromley health authority has carried out extensive surveys of the population, their health and their mobility. It has assessed the population's diverse health needs. It has undertaken public consultation and it has organised public meetings and private groups—a process that is continuing with small groups of local people being invited to show their expectations of local health services. As a result of that process, it has developed, among other things, a local rest care service. It has brought plastic surgery consultants into local clinics. It has established a local alcohol detoxification service, run by a voluntary body, on whose management committee I sit. The authority has established local mental health teams and devoted extra resources to help promotion. All those policies have stemmed from local consultation.

The health authority has been pursuing the targets in the patients charter, especially in relation to reducing waiting times for both in-patients and out-patients. It has encouraged the use of day surgery. It has had to handle reduced funding, resulting from the operation of the weighted capitation formula, but it has remained within its cash limit and within its budgets. A part of the reason for that success is the operation of the internal market, criticised frequently, and in their motion, by the Opposition.

Bromley health authority has been able to improve the terms of the contracts that it has negotiated, both in the health authority area and outside it. For example, it has been able to save some £500,000 on placements in nursing and residential homes, without reducing the number of placements. The bulk of treatment is undertaken in the health authority area in four hospitals, some of whose facilities are in old and out-of-date buildings. Our great need is to have one modern, fully-equipped acute general hospital.

My right hon. Friend the Secretary of State will be aware that plans are well advanced to redevelop Farnborough hospital to produce a new hospital with the latest facilities for acute services, and with a modern accident and emergency department. I hope that, when those proposals come to her desk, she will give them a favourable response, so that my constituents can have the service to which they are entitled.

Even when we have our acute general hospital, and notwithstanding changes in the pattern of medical provision, which my right hon. Friend outlined in her speech, some patients from outer London and further afield will still come to inner-London hospitals, including Guy's hospital, for specialist treatment, as they have been doing for some years. I remind hon. Members that, some years before the Tomlinson proposals, discussions had been taking place between both administrative and clinical staff at Guy's and St. Thomas's hospitals to affect a rationalisation of services and a better use of the resources available. Those discussions, however, did not come to any consensus and, 12 months ago, my right hon. Friend the Secretary of State stepped in and issued what I think was described as a strategic direction.

I give my right hon. Friend all credit for at least doing something to try to break the logjam, but the more I consider her decision, the more I fear that it may have been based on inadequate and inaccurate information. The effect of her direction would be to close the accident and emergency department at Guy's, to move most in-patient services from Guy's to St. Thomas's, and to make Guy's mainly a teaching and research hospital. Not surprisingly, there was widespread reaction to those proposals, and it led to the setting up of the "Save Guy's Hospital" campaign, chaired by the hon. Member for Southwark and Bermondsey (Mr. Hughes), the local Member of Parliament, and co-chaired by the hon. Member for Dulwich (Ms Jowell) and myself. Hon. Members will be aware that, among other things, the campaign promoted a petition that attracted well over 1 million signatures, and that was presented in the House just over a year ago.

Mr. Simon Hughes (Southwark and Bermondsey)

It was presented just over a week ago.

Mr. Sims

I apologise—it was presented just over a week ago. It is a year that we have been working on this matter. The proposals and alternative suggestions have been the subject of detailed discussion and debate.

In the interests of other hon. Members who wish to make speeches, I shall not detain the House by going through all the considerations, but I shall make three points. First, hundreds of my constituents, and many of the constituents of my hon. Friends, travel daily to, and work in, the City of London. Surely the City needs an A and E department not only for the everyday accidents and illnesses that occur whenever a large number of people are gathered together, but for major incidents such as a terrorist outrage or a train crash, which might happen at any time in the City. With the closure of the A and E department at Bart's hospital, the continuation of an A and E facility at Guy's hospital is essential.

Secondly, thousands of patients throughout south-east London and, indeed, south-east England, are referred for specialist consultation and treatment to Guy's. They, their relatives and their friends have maximum ease of access to that hospital, which is sited literally next door to London Bridge station, with rail services throughout the south-east, and to a large bus station. Apart from all the other considerations, closing the facilities at Guy's and moving them to St. Thomas's would be very much to the disadvantage of a substantial section of the south-east England community. One feature of the Guy's site is Philip Harris house, to which reference has been made. It was designed and equipped specifically to provide the latest treatment and specialist services at a cost approaching £150 million. Surely it cannot be right not to use that building for the purpose for which it was constructed and equipped.

The "Save Guy's Hospital" campaign commissioned KPMG to report on the implications of the proposals and to suggest alternatives, and the campaign made its own proposals. They are being considered and will reach my right hon. Friend's desk in due course. I realise that she cannot comment now, but when it is time to reach a decision, I hope that my right hon. Friend will meet me and hon. Members from all parts of the House, together with those particularly concerned, to hear our views. I am sure that my right hon. Friend and my hon. Friend the Minister of State want, like me, to ensure the best health care for the people of London and the south-east.

5.10 pm

Mr. Simon Hughes (Southwark and Bermondsey)

I am grateful to be called, and grateful to the Labour party for choosing this subject for debate. We have been around this circuit before, but clearly it is necessary to go around again.

It will not surprise the Secretary of State and the Minister to hear that health care is chief among all the issues that currently preoccupy my constituents. That issue probably preoccupies Londoners most, too. Saturday's conference at the Queen Elizabeth II centre, organised by the Evening Standard, was attended by more than 1,000 people. That shows the interest and concern of the people living in our capital.

The hon. Member for Chislehurst (Mr. Sims) pointed out that that concern about London health care does not stop at the Greater London boundary. Traditionally, concern about London's health services is felt throughout the country and all over the world, because patients, students and practitioners are all part of the global network on whom the London health service has always depended and will continue to depend.

At present, there is a dialogue of the deaf. The motion say that there is a continuing crisis of health care in London". The Government answer, "Oh, no, there isn't." The Government say that the health service is getting better. That gets the response, "Oh, no, it isn't." Somehow, the messages are not getting through.

However well the Government think they are doing, they have not persuaded the public—certainly not in the capital—that they are doing well.

Mrs. Barbara Roche (Hornsey and Wood Green)

Is the hon. Gentleman aware that one of my constituents, a man of 78, had a prostate operation at the Whittington hospital cancelled because of lack of funds, and has been given no future date? While such incidents continue, the Government will find it impossible to persuade the people of London that they should have confidence in the capital's health service.

Mr. Hughes

Such incidents certainly lower confidence in the system. To be fair, the Government understand that. Recently, waiting lists in London have grown—there is no argument about that. Both the number of people on the lists and the time that they must wait have increased.

The public think that more money should be in the kitty for the national health service. I appreciate that this is not principally a decision for health service Ministers, and we heard an announcement today about more money, which is welcome. The Government must not be troubled by any belief among the public that money should not be spent on health care delivery, because the opposite is true. Opinion polls show that 80 per cent. hold that view. However, the public are suspicious about the £1 billion spent on the management sector of the NHS.

I am not arguing that London should get more than its fair share of the cake. A fair share is, of course, difficult to determine. It should be based not just on residence but on the number of outsiders who use the London health service—the hon. Member for Chislehurst and others spoke of such referrals. People are still not persuaded that the recently revised weighted capitation formula is just. It is not understood, and many suppliers and purchasers do not think it is fair. My local health commission believes that it should be given another £100 million a year. The money that is available is not shared equitably. The capital has a huge mix of deprived and not-deprived areas, and funds do not seem to reach deprived areas to anything like the extent they should.

The problem is not a lack of facts or accurate facts, but, because of their complexity, the facts are subject to all sorts of interpretations and misinterpretations. It is crucial that decisions are based on up-to-date, accurate facts.

Of course the Government's amendment is true to some extent, because Greater London's population has been declining. Of course it is right that people who do not need to come London are treated elsewhere. Of course there have been desperately needed developments in primary care. When the Minister visited my constituency, he saw a much better GPs' surgery than before, when it was in an old building down the road. However, we cannot spend more money on primary care—which I welcome—to the detriment of necessary acute care for Londoners whose acute care centre is the district general hospital.

If the figure for beds per capita in London is lower than the national average, and if waiting lists are larger and longer than the national average, I hope that the Minister agrees that the question is not the number of beds that exist but the number needed. At present, London does not have the beds it needs. I accept that fewer are needed than five, 10 or 20 years ago, but the current number is insufficient.

Beds are often 100 per cent. full. The inner-London chief executives have just said that 85 per cent. was a safe bed occupancy rate. The hon. Member for Dulwich (Ms Jowell) said that that is rarely, if ever, the case. I argue not for an ever-increasing number of beds but for enough, and not to make it look as though more patients are being treated by throwing others out so quickly that they must be readmitted the next day or week—particularly the elderly—because they are prematurely discharged and returned home for inadequate care.

I do not oppose the idea of a review and of the Government saying, "We must grab the problems of London's health service by the neck and solve them." What I oppose is the fact that decisions are taken on the basis of information that is inadequate or inaccurate, and which is not then brought up to date.

I give a specific example. Professor Tomlinson now says that he was not given all the information he needed. The most contentious example is the fact that when he was shown the trend in the number of people admitted to hospital beds, he was shown only the figures for the most recent months before his report, and was not shown the figures for the period before that. The figures for the couple of months before the report showed a downswing, whereas the previous year's figures showed a consistent increase. Such a misunderstanding, which was not Professor Tomlinson's fault but a result of inaccurate information, led to conclusions that are now working their way through the system.

Since then, Professor Jarman has shown that Professor Tomlinson was wrong; Professor Tomlinson has admitted that he was in part wrong. In the past couple of weeks, the inner London chief executives have brought matters up to date since Jarman. On the radio this morning, the Minister said, referring to Tomlinson: nothing has really changed since then. Some things have changed, and I can prove that to him. In addition, some of Professor Tomlinson's conclusions were wrong because he was misinformed.

Let the Minister have his review, and let him look at the evidence. I do not think that he is acting in bad faith. Let his evidence be accurate, and let it be updated by the facts. The review will then have the confidence of the people of London. The analysis must be right, and the changes must be brought into focus and accurately represented. For whatever reason, many more people have gone into accident and emergency units in the past year than in previous years. I do not know why, but I know that it is a fact. If it is a fact, it must be taken into account.

I am not here to defend vested interests in the professions. However, specialists, who are perceived by the Government to have vested interests, are often specialists in great institutions, which are not only great institutions, but the places that treat the poorest and the most deprived in our communities. They are the most important institutions.

I have no compunction about saying in the House that the most valuable building in my constituency is Guy's hospital. Unarguably, it has done the most good for the most people over the longest period. The patients and the taxpayers are the only vested interests about which I am concerned—the people who pay for and use the service. What do they want?

The people who pay for and use the service want large hospitals for specialist services. I understand all the arguments about that and I understand that having small accident and emergency units without adequate back-up is no good. However, there is no theological answer to the question of what the right size is.

Above all, a different view should be taken about accident and emergency departments. Other specialties are much more high-tech and can be more limited in number around the country. There should not be replication of a service, whether oncology, renal services or paediatric services, between one hospital and the hospital next door, because that would be a waste of resources. There should be rationalisation and consolidation.

However, services that the community needs should be located where the community is. It is no good—taking the argument to its logical conclusion—having a massive hospital with wonderful facilities that is not near enough to be of use to the people it is meant to serve. One cannot make decisions irrespective of the location of the communities and the users.

There is one other point about which I want to persuade Ministers. All acute general hospitals should have elective beds—beds that are not used for emergencies, to which people can be admitted to have operations for which they have waited. People should not have the experience of the constituent of the hon. Member for Hornsey and Wood Green (Mrs. Roche), who kept being told that he could not come in because of emergency cases. All acute general hospitals should have ring-fenced elective beds.

London communities are just as entitled to community acute health care as all other communities. Let us assume that my constituency has the same population as the county of Herefordshire. No one argues that people in Herefordshire should go to Birmingham for less specialist treatment. They should get treatment in Herefordshire, and the same point should apply to London. London also needs low-dependency beds and—this is hugely important—nursing homes and residential homes where there are low-dependency care opportunities for the elderly. In inner London, there are hardly any.

I want the Government to get things right. The problem is that people do not have confidence in the process because the precedent does not give them confidence. Many times, facilities have closed and we have not had a replacement service to come to the rescue or, in many cases, a better service. People are, therefore, sceptical and need to be persuaded. Above all, if there is to be change, people need to know that the alternatives are in place and that they are working well.

I conclude with the example about which, as the Minister knows, I am most concerned.

The Minister for Health (Mr. Gerald Malone)

I have listened with interest to the hon. Gentleman, and I underpin his point that the momentum needs to be maintained. Before he moves on to what I know to be a subject close to his heart, would he tell the House what he thinks about Labour's proposal that there should simply be a review and a total moratorium?

Mr. Hughes

I can answer that question. I do not think that we can ever have a standstill, because the patterns of health care and of need never stand still. I am not arguing that we should stop everything for an indefinite period. I am arguing that there should be a perpetual review, with periodical decisions every five or 10 years, so that everybody knows what we are talking about.

At the moment, we should work within a timetable set by the Government; they are perfectly entitled to set such a timetable. I shall suggest how we could take decisions in a way that would achieve the right results. I am trying to be helpful, because I believe that we have to break through some of the traditional failures in the health care structure in London.

We must have decisions that command confidence. I take the example of Guy's and St. Thomas's. According to the proposals, the accident and emergency unit at Guy's will not be run down until 1996 at the earliest. Ministers can go with the existing proposals and say that they will not look at things again. They can say that they will close the unit and that the provision will shift. That is setting one hospital against another. Such a decision set Bart's against the London hospital, and it is now setting Tommy's against Guy's. The decision sets people against each other, because it is taken by a few people behind closed doors.

Alternatively, Ministers could say, "This is the total money you will have. You work it out. You decide what your priorities are and where your services should be." The great benefit of that would be that the hospitals would have to work together and come to a conclusion. The Minister could say to us in south London, "This is the money; you will not get any more, because of the way in which the contracts work. You make the decision."

I guarantee that the GPs, the community health councils, the Members of Parliament, the local councils and the community would agree to make that decision. We would make decisions to rationalise across the Guy's and St. Thomas's sites, but we might well decide that the priority was to open Philip Harris house for its full purpose, and to keep accident and emergency units on both sites.

I now turn to the reason why Ministers have to get it right. I am trying to help them not to get it wrong again. On 25 July 1991, the Prime Minister wrote to Peter Griffiths, who was then chief executive of Guy's hospital. He said: Thank you so much for helping to make our visit yesterday to Guy's Hospital such a successful and memorable occasion. It was most interesting to learn more of the Guy's and Lewisham trust and its work. I was also struck by the positive attitude of not just the Board or senor management, but of all the staff I spoke to. I am sure Guy's will continue to lead the way in the development of the Trust concept throughout the county. Norma and I would be grateful if you could pass on our congratulations to all those who helped to organise yesterday's 'Topping Out' ceremony and visit. That letter was written four years ago. Today, there is not wonderful morale at Guy's hospital, there is not great confidence that it will lead the world in the development of the new flagship concepts of the trust, and the local community does not feel reassured.

On 6 February, a note was sent internally to directors by two people in the local health commission, entitled "Meeting the Needs of the Residents of Bermondsey and Rotherhithe". In summary, it said: We have demonstrated that the proposed acute changes will in the short-term make the poor health care provision in Bermondsey and Rotherhithe worse. There is no excuse for the Government making decisions that make things worse. I hope that they will listen to those of us who are trying to ensure that they do not make mistakes, so that, for everybody in London, especially those who use the London health service, the health service can be better, as—I hope—we all wish to see.

5.29 pm

Mr. David Congdon (Croydon, North-East)

I welcome the debate. It is the third one on London's health in the past 10 months. It is unfortunate, however, that Labour Members have deliberately sought to exaggerate the problems in London to try to give greater force to their argument. I intend to outline what I consider to be some of the problems, because it would be foolish to try to pretend that there are no problems when change is being engineered and implemented in the capital city.

Any changes on the scale outlined in "Making London Better" and before those in the Tomlinson report, were bound to cause a degree of uncertainty. Change always causes uncertainty, and always causes fear. That has not been helped by Opposition Members—and, dare I say, some consultants and doctors in the hospitals concerned—whipping up that fear. It has made it much more difficult to conduct a rational debate on the important health changes in London.

No one likes to see great institutions under threat of closure. My plea to the Minister is that, while we must rationalise the provision the London—I shall say why in a moment—we should tread very carefully before we succumb to grandiose schemes involving millions of pounds of capital expenditure, on a wing and a prayer that they will lead to minor revenue savings.

I do not want to develop that point too much, but I make it with particular reference to proposals for St. Bartholomew's and the Royal London, which involve £250 million of capital expenditure. Coming from an outer-London borough, where we have always pressed for further developments in our district general hospital, as indeed has Bromley, the neighbouring borough, I repeat that we should tread with great caution before we accept such grandiose proposals.

We must also recognise that the status quo in London is not an option. It was interesting that the right. hon. Member for Derby, South (Mrs. Beckett) did not say that this afternoon, unlike her predecessor, the hon. Member for Sheffield, Brightside (Mr. Blunkett), and, indeed, Baroness Jay. Most people involved in the national health service and with an interest in health matters have recognised for many years that there has been an over-concentration of teaching hospitals and resources in inner London. To one who represents an outer-London constituency, that has been only too apparent on the ground, since outer London has far fewer health resources than inner London.

There has been much bandying about of statistics, yet they appear to be a moveable feast, as reports are published two to the dozen. As far as I can make out, spending in inner London, as quoted on previous occasions, has been 47 per cent. above the national average per person, excluding spending on the special health authorities. Including spending on special health authorities, the figure rises to 57 per cent.

Much play has been made of beds. My understanding, again on figures previously quoted, is that in inner London there are 3.3 acute beds per thousand of the population, compared with a national average of 2.33 per thousand. Even today, in the second King's Fund London monitor report, which I received this morning and have studied at great speed to see if the statistics add up—

Mr. Nicholas Brown (Newcastle upon Tyne, East)

They do not add up.

Mr. Congdon

The hon. Gentleman is right, they do not add up. The problem with the report is that it talks of London as a whole. None the less, it says that there are 8 per cent. more available acute beds per capita in London than there are in England as a whole. What is more significant is that 40 per cent. of those beds are in inner London. There is a preponderance of beds in inner London. We also know that the length of stay in teaching hospitals in London is 15 per cent. above the average for the provinces.

The right hon. Member for Derby, South made great play of the fact that, in a sudden surge of inspiration, she had managed to determine that somehow the figures for London were not valid, because London was no better off than comparable cities up and down the country. Yet we knew that, because it was clearly stated in the original King's Fund report, which preceded the Tomlinson report and "Making London Better".

Therefore, we are not debating London only, because the situation in London is comparable to that in other cities that also have to get to grips with problems. However, that does not negate the need to make progress in London. Despite all those figures—possibly because of the apparent over-provision—London has poorer primary care.

I shall address some other aspects of health care in London. I was very pleased that the hon. Member for Southwark and Bermondsey (Mr. Hughes) mentioned the funding formula, because I think that it is important. Again, it was interesting that the right hon. Member for Derby, South did not remind the House that the original changes to funding, which have affected London so seriously, go back an awful long time, to the doctor who was a Minister of State for Health, Lord Owen. He introduced the resource allocation working party formula, which took funds away from London. Certainly Croydon has suffered from that ever since.

There have also been recent changes to the funding formula which benefit Croydon. Whereas, before, the borough was about on target, it is now £6 million under target. However, I was somewhat disconcerted to learn from figures that I received only today from the South Thames regional health authority that the South East London health authority, which was apparently £5 million under target, is now £4 million over target.

I urge Ministers to look again at the funding formula. I know that they have relied heavily on work done by York university, but there is still concern that too much weight in the formula is given to the age profile of the population and the number of elderly people, rather than to deprivation factors, which clearly have a significant impact on health spending.

We are well aware of the other pressures for change. The switch from secondary to primary care is leading each purchaser to reduce the percentage of funding it spends on secondary care. There is a welcome trend of more patients being treated near home. I know that my hon. Friends who represent constituencies outside London welcome the fact that their constituents do not have to travel to London for care, and that they can receive such treatment at their local district general hospitals.

We have also heard about the significant switch to day surgery. It is obvious that beds are not needed for day surgery. At my local hospital, the Mayday University hospital, 90 per cent. of cataract operations are now carried out on a day basis, much to the benefit of the patient. Micro-techniques have led to much less invasive surgery, which also means shorter stays in hospital. All those pressures justify the general strategic direction that the reforms and changes are taking in London.

I mentioned earlier the King's Fund, the Tomlinson report and "Making London Better". It was significant that "Making London Better" scaled down the figures for bed losses as outlined in the Tomlinson report.

Although it was not really a target, "Making London Better" refers to a bed loss of between 2,000 and 2,500 beds in inner London in comparison with the 1990–91 figure. In last October's debate, I drew attention to the fact that, if London could improve its efficiency of bed usage to the level of other areas in England, that target could be achieved easily. If London could reach the level of 14 beds per 1,000 in terms of the population in inner London, 2,700 beds could he taken out of the system.

That is not the end of the story. There is clearly a serious dichotomy between the strategic direction and analysis of the situation in London and what is happening on the ground today. I castigated Opposition Members earlier for over-exaggerating the problem. I believe that they do that, but it would be foolish to deny that there is pressure on beds in London.

One need only visit accident and emergency departments to witness the pressure that they are working under. I visited the A and E department at Mayday hospital recently. I did not visit at its busiest time, but it was very cramped. I am pleased that major redevelopment is going on at the moment to provide proper facilities. When facilities are cramped and there are problems with getting people into beds in hospitals, there is the dreadful phenomenon of people having to spend time on trolleys. That is clearly unacceptable.

The picture with regard to health in London is confusing, because it is rapidly changing. Reference has already been made to the report entitled "Hospital Services for Londoners" by the inner London purchasers. The report makes several points. Interestingly, it refers to the fact that accident and emergency attendances had not changed significantly. That is surprising, because, from anecdotal evidence, some people had felt that A and E attendances had increased.

It is noteworthy that emergency admissions, whether via an ambulance on a 999 call, or via an ambulance bringing in an urgent case from a GP, have increased significantly. One of the difficulties that I have found with the inner London purchasers' report is that it does not provide the figures. It does not give the scale of the increase.

I am aware that my district general hospital, Mayday in Croydon, has seen an increase of 25 per cent. in emergency and urgent admissions in comparison to January last year. We have had a very mild winter this year. As far as I am aware, there has been no great spread of illnesses, such as a large epidemic of influenza, which would have had a significant impact on such admissions.

I do not know whether the increase in Mayday's emergency and urgent admissions is mirrored across London. I would be surprised if it was, because the figure is extraordinary and it cannot be explained by straightforward demographic factors. I urge my hon. Friend the Minister to ensure that that aspect is considered.

I wonder whether all A and E departments in London are pulling their weight and taking their share of cases that come their way. I wonder whether some are closing their doors from time to time, putting pressure on other hospitals. If that is the case, it would clearly be unacceptable.

While we are right to press on with the strategic drift of the changes in London, we must be cautious about losing further acute beds too quickly in London. I have received figures only today—today seems to be my lucky day—which show the bed position in London until March 1994. It would obviously be helpful if there were more up-to-date figures.

I was particularly interested in the bed loss figures in inner London. Compared with "Making London Better" and Tomlinson, and the target of 2,000 to 2,500 bed losses in five years, 1,400 beds have been lost in inner London. It is interesting that, between 1991–92 and 1992–93, the bed loss was comparatively small, but it accelerated between 1992–93 and 1993–94. It is possible that that, in conjunction with the implementation of care in the community, in respect of which we know that there is a problem in getting elderly people out of hospital quickly enough because of problems with discharge, is a factor in influencing the pressure on admissions to hospitals in London.

From talking to my district general hospital, my impression is that it is quite possible to reduce surgical beds even further, because of the advances in medical technology to which I referred earlier. However, it is difficult to reduce medical beds which tend to be used mainly by the elderly. Indeed, my hospital has had to open additional medical beds to cope with the demand, and I urge my hon. Friend the Minister to consider that aspect in more detail.

In addition to the inner London purchasers' report, the clinical studies advisory group has produced a very useful report into A and E admissions and how A and E departments should be organised. I refer to those two reports because they make important recommendations.

There is no doubt that there is a need to improve the management of A and E departments and to ensure that they have proper observation wards and, perhaps even more importantly, admission wards, so that people do not spend time on trolleys. The inner London purchasers' report states that some hospitals are operating to too tight a margin.

If there is very high demand in a hospital, particularly on the emergency admissions side, the inner London purchasers' report makes it clear that the occupancy level of beds must be lower than would otherwise be the case if the level of emergency admissions was lower. That stands to reason, because if a hospital caters primarily for elective surgery, with very few emergency admissions, it can plan for that, and it does not need the slack for emergencies. However, if a hospital has a very high percentage of emergencies, there could be a sudden surge, which could completely disrupt the hospital. That hospital therefore needs greater spare capacity.

The inner London purchasers' report states that hospitals should operate at a level of about 85 per cent. I do not know whether that is a good suggestion or a bad one, but it must be borne very carefully in mind. The report also suggests that, in assessing bed requirements, one particular formula to be applied across London is not necessarily the correct approach. The health authority should assess the needs in its area before reaching a conclusion about bed requirements.

The report makes another important point. We know that London has more acute beds per 1,000 of the population than elsewhere. Interestingly, it has fewer nursing home places. That causes more pressure on medical beds, and that is why we must proceed with caution before reducing those beds further.

The report by the clinical studies advisory group is interesting, covering issues such as bed management. That issue is crucial in any hospital. Too often, there are problems in getting patients on to wards. However, sometimes beds are being kept vacant by consultants. Hospitals must manage beds properly.

It is also important to ensure proper consultant cover in A and E. Too often, patients turn up in A and E and find that the more junior doctors are on duty.

The NHS does an excellent job catering for most people when they are ill. If one is seriously ill or in a major road accident, generally speaking one will be treated very well indeed. But it is not acceptable to have the main entrance to the NHS in A and E departments which are often not staffed by senior consultants and which are often short of facilities for getting patients out of A and E and into the main part of the hospital. That aspect of health care is critical, and it must be given priority.

I shall say a couple of brief words about some specific changes in London, of which great play has been made. There has been concern about the closure of Bart's A and E department,. but I am hound to say that, given that it catered for only 30,000 attendances a year, it was right to centralise facilities elsewhere. Indeed, those facilities have been expanded. I welcome also investments in A and E at various centres within London, including King's, the Homerton, and the Mayday in Croydon.

I do not think that there is a crisis in the health service in London. The changes that have been set in train are proceeding in the right direction. However, I agree with the hon. Member for Southwark and Bermondsey, who made the plea that responsibility for bringing about those changes in the configuration of particular trusts should be left to them, rather than be determined by the center—but with the one key reservation that I have mentioned.

I hope that my hon. Friend the Minister will not agree to massive capital injections where they are not necessary. I urge my hon. Friend to be cautious in relation to further acute bed reductions, given the evident pressures on beds at present. I am happy to support the amendment.

Several hon. Members

rose—

Mr. Deputy Speaker (Mr. Geoffrey Lofthouse)

Order. We have 39 minutes before the winding-up speeches commence, and four hon. Members hope to catch my eye. I hope that they will be successful.

5.51 pm

Mr. John Austin-Walker (Woolwich)

The hon. Member for Croydon, North-East (Mr. Congdon) talked about Opposition Members whipping up fears, concerns and anxieties. If he had been at Saturday's conference, which was organised by the Evening Standard, to which reference has been made, he would have seen for himself that such fears, anxieties and concerns need no whipping up and that they are genuine.

I shall say something about the lack of strategic planning, control and accountability in London. I start with the London ambulance service. It has been apparent to the general public for many years that things are wrong with the London ambulance service. In 1991, I was involved in a report that was produced by the Association of London Authorities, entitled "London's Ambulances—a Service in Crisis". At about the same time, the National Union of Public Employees produced a report spelling out the difficulties that the London ambulance service faced. Those reports went to Mr. Wilby, the chief executive of the London ambulance service, and to the right hon. Member for Bristol, West (Mr. Waldegrave), the then Secretary of State for Health, and they did nothing about the matter.

We then had the computer crash in October 1992, when the Minister and the Secretary of State said that they would address the serious problems. Since then, we have had the Wells report, which confirmed what Opposition Members had been saying for a long time—that is, that there had been a history of underinvestment and a lack of funding within the London ambulance service. When the Wells report recognised that and made recommendations, the Secretary of State said that it was nothing to do with her and that it was a matter for the region.

I now refer to the contrast in accountability in the London ambulance service and the London fire and civil defence authority. My hon. Friend the Member for Holborn and St Pancras (Mr. Dobson) has called it a tale of two services. The London fire brigade provides a first-rate service; the London ambulance service does not. The London fire brigade meets its performance targets; the London ambulance service does not. The London fire brigade successfully introduced a computerised mobilising system; the London ambulance service did not. The London fire brigade has successfully set about revising and improving its management structure and working practices, whereas the London ambulance service has not.

The difference between the London ambulance service and the London fire and civil defence authority is that the London fire brigade is accountable to a body of responsible elected representatives from each London borough. We would not have had the crisis in the London ambulance service if we had had the accountability that we have in the LFCDA.

The London ambulance service has an appointed board that meets in secret. Not only are its minutes not available, but its agendas are not available for inspection, either. I understand that its minutes were not even available to the Page inquiry, which investigated problems within the London ambulance service.

Let me deal with another aspect of the lack of control and the lack of accountability. My hon. Friend the Member for Leyton (Mr. Cohen) has been trying to ascertain figures for the number of hospitals in London that have closed since 1979 and the number of beds that have closed. He has had a very hard task of that within the Library, because he has been told that there is no central source of that information. The Department of Health does not even collect the number of hospitals any more, let alone details of their closures.

After much research, my hon. Friend the Member for Leyton found that between 1979 and 1993–94 the total number of NHS hospital beds in London fell by a staggering 49 per cent., from 64,850 to 33,120. Acute beds fell by 45 per cent. and non-acute beds by 53 per cent. That is one of the consequences of the Government's policies and one of the reasons why the crisis exists. Unlike the hon. Member for Croydon, North-East, I believe that there is a crisis within the health service in London.

I now refer to what some might think is a parochial issue, but it shows quite clearly the lack of accountability and the lack of control within the national health service in London. The catalogue of local disasters in the Greenwich area was put before the House in an Adjournment debate on 28 January last year. In that debate, I expressed my concern about the management of Greenwich health care trust. Indeed, my hon. Friend the Member for Greenwich (Mr. Raynsford) and I called for the chief executive's resignation. I felt that somebody should be responsible. Somebody should be accountable, particularly when that person, Mr. Bruce Joyce, appears to have been one of the 10 highest-paid chief executives in the country. I was pleased to learn from the new trust managers that Mr. Joyce had not claimed any performance-related pay when he left the service. What a pity. On the record of his negative performance, he probably would have owed us something.

I am disturbed to read, however, in the Woolwich and Plumstead News Shopper that a BBC documentary alleges that Mr. Joyce, who retired to spend more time with his family, received a pay-off of between £200,000 and £400,000. Unfortunately, no one at the trust was available to comment. The Minister is available tonight, and I await his comment with interest.

Let me now deal with a matter that I have raised with the Minister. In April 1993, the Brook hospital took delivery of a second-hand magnetic resonance imaging scanner. In about September of that year, it came to my attention that the scanner was not working. It was alleged that there was something peculiar about the way in which the purchase had been arranged, that staff had not been properly trained, and that the scanner was incompatible with other equipment. I received assurances that the staff had been trained, that the scanner was compatible, that it was a shared purchase between the region and the Brook hospital, and that it was settling in and would be up and running soon. It was not.

I raised the matter with the Secretary of State on 29 October 1993. On the same day, I asked her how many beds had been closed and how many operations had been cancelled for financial reasons. The hon. Member for Bolton, West (Mr. Sackville), the Under-Secretary of State, told me that the Department of Health did not keep such information and that the scanner was nothing to do with the Secretary of State; it was a matter for managers and clinicians".—[official Report, 29 October 1003; Vol. 230, c. 835.] The Minister referred me back to the trust, which referred me to the region. The scanner—£500,000 of hardware—had still not scanned a single patient. On 18 January 1994, I queried the purchasing arrangements with the Secretary of State. That time, I was referred by the Under-Secretary of State to the chairman of South-East Thames regional health authority.

I raised the matter in an Adjournment debate in January 1994. Half a million pounds-worth of scanner was sitting idle while £116,000 a year was being paid to a private hospital to provide a scanning service. Eight months after the scanner was purchased, the Under-Secretary of State said: I share the concern expressed by the hon. Member for Woolwich about the commissioning of the MRI scanner, but, following the trust's inquiries into the matter, we will ensure that any procedural shortfalls are addressed. I understand that a meeting is to be held shortly."—[Official Report, 28 January 1994; Vol. 236, c. 600.] On 15 December 1994–18 months after the scanner was delivered, 15 months after I raised the matter with the trust, 14 months after I raised the matter with the Secretary of State and 11 months after the Under-Secretary said that a meeting was to be held shortly and that shortfalls would be addressed—Greenwich health care trust and the South Thames regional health authority put out a joint press statement that they would be disposing of the scanner, which had never worked. Following an independent district auditor's review, they admitted weaknesses in the procurement procedures, breaches of the region's standing financial instructions and weaknesses in the trust's management of the project. Both the chief executive and the chairman of the trust have now departed. At least the new incoming acting chairman, who inherited the mess and a variety of others, admitted that the episode had hurt the Trust and the taxpayer. It has been revealed that of the £416,000 purchase price, £117,000 came directly from the region and the other £299,000 came from Greenwich health authority's charitable trust funds. That one third of a million pounds was not taxpayers' money, but money donated by local people and grateful patients with an affection for their local hospitals. The money was often left in wills and legacies for improvements to local health services and added comforts for people at local hospitals.

That piece of equipment—although installed in a local hospital—was not for a local purpose. It was for the region's specialist neurosciences department, which the region and the Secretary of State had already agreed should move to King's College hospital in Lambeth in the spring of 1995. Why was the local health authority inveigled by the region into using local charitable moneys for a regional service that was about to transfer out of the area?

I have asked the region to reimburse the local charitable funds, but the regional chairman tells me that that would be impossible as it would be ultra vires. But if the region breached its own standing financial procedures, and that went unattended by the Secretary of State for so long, was not the purchase ultra vires in the first place? If the region cannot reimburse the funds, I believe that the Secretary of State should.

I shall refer briefly to psychiatric services. It is a year since the report into the Clunis affair, and a year since the Health Select Committee published its report, "Better Off in the Community". Both pointed to the fact that there is a crisis in psychiatric care within the capital.

Psychiatrists across the capital have warned in recent months that the Government's care in the community programme cannot cope with the tide of demand for hospital beds for people with mental illness in London. Studies have shown that, across the capital, the average unit has a bed occupancy rate of between 100 per cent. and 120 per cent. What are psychiatrists to do in a crisis when all the beds in London are full and there are no beds throughout the south of England?

Last September, a survey by the Royal College of Psychiatrists revealed that, during one week, 84 people in London who needed hospital treatment were turned away, while a further 24 were prematurely discharged. The college calculated that an extra 426 beds were needed immediately to deal with the unmet need.

In my area, the bed occupancy rate is 120 per cent. When space runs out, patients are referred to other hospitals—often private hospitals—as extra-contractual referrals, sometimes as far afield as Woking or Oxford. Finding an extra-contractual bed is no easy task. Local psychiatrists have told me that it is not uncommon for calls to be made to up to 35 different hospitals before a place can be found, with patients having to wait 24 to 36 hours to be placed.

In 1990, researchers at Central Middlesex hospital predicted a bed famine if London's mental health beds continued to be closed. I do not dispute what the hon. Member for Croydon, North-East said about the need for change, but it is the pace of change that concerns us. It needs to be balanced change. The rundown and closure of beds and institutions without adequate alternatives being provided is causing the crisis in the capital's health services, and a crisis it is.

In support of the plans to cut beds still further, the Secretary of State relied heavily not only on Tomlinson but on an earlier report by the King's Fund. She appears less keen to accept the King's Fund's subsequent findings in "London—The Key Facts", which was published last April. The document stated that the capital's health care needs have been underestimated. There are now good reasons for believing that London merits a larger—not smaller—share of the NHS cake". The Secretary of State also appears unwilling to accept the King's Fund's proposition that purchasing power for hospital and community health services in London should be increased by approximately £200 million". Professor Jarman's findings have been mentioned by my hon. Friends, and they were reinforced by a recent update by James Raferty of the Merton, Sutton and Wandsworth health authority and Nigel Edwards of the London Health Economics Consortium. They stated that in 1992–93, the loss of 400 beds would have equalised London's position with the rest of England, but 1,499 beds were lost. They identified particular problems for elderly people, as London has a severe shortage of nursing home and residential care.

Those problems are leading to a crisis, but it will not be solved by cutting more beds. We must provide the resources and facilities elsewhere, and my hon. Friend the Member for Dulwich (Ms Jowell) was absolutely right on that matter. If there is validity in the theory that improvements in primary care will lead to a lessening demand for hospital beds, let us have those improved community GP services up and running before the beds are taken away.

The Parliamentary Office of Science and Technology bears out the view that if we improve primary care—particularly access to primary care for those who are currently denied it—we increase the demand upon hospital beds and specialist provision.

I started by talking about accountability. Despite assurances that primary health care would be prioritised as hospitals close, there are now fewer GPs and health visitors in London than there were three years ago. Londoners have no voice in the current arrangements. The patients charter promises patients a greater say in their own health care, but, with no democratic accountability, Londoners find themselves on the receiving end of chaos and cuts.

6.7 pm

Lady Olga Maitland (Sutton and Cheam)

I am an enthusiastic supporter of the NHS. My children took advantage of the NHS, and my parents also take advantage of the service. I can say unreservedly that my family is entirely satisfied with the treatment that we have received.

I do not see a crisis in the NHS. I see challenges and opportunities in today's world. Modern medicine is making tremendous advances and is giving us untold opportunities to provide the very best patient care. I congratulate my right hon. Friend the Secretary of State on her positive and caring speech. She has given many examples of investment in the health service and in patient care. I do not believe that anybody could have any doubts about her commitment.

This debate has been full of gloom and doom. Opposition Members have run down the health service and have tried to frighten potential patients into believing that they will never get real service and care. The facts provide a totally different picture. More patients are being treated than ever before. Why do not the Opposition give credit for that? The length of time for which patients must wait for treatment has fallen sharply. Why do not the Opposition give credit for that? Health care and health have improved dramatically in the past few years, while life expectancy has risen by two years for men and women. The perinatal and infant mortality rates have fallen by more than two fifths since 1979. Why do not the Opposition give us credit for the work that we do in the health service?

Why do not the Opposition even mention that for three years in succession our immunisation programme has been so successful that no child in Britain has died of measles? Why do not they tell us that services at doctors' surgeries have improved, that there are now fewer patients on a doctor's lists and that the number of practice nurses has risen from 900 in 1978 to more than 8,500 in 1992? Why do not they give us credit for that?

Why do not the Opposition tell the patients the good news rather than try to terrorise them? Why do not they admit the success of the patients charter? Should not the patient have the right to know the success and the results produced by a hospital? Should not patients have the right, which we have now given them, to be guaranteed a standard of service? I have not heard the Opposition mention once the success of the patients charter this afternoon. Are they simply frightened to admit success when it is happening?

Why do not the Opposition accept that once again the Government have increased spending in real terms both last year and in the forthcoming year? The Opposition talk about a shortage of beds. I put a question to the Opposition, which I am sure will be answered during the replies to the debate. If they are so worried about a shortage of beds, as they allege, I am sure that they will support the Government's NHS reforms, their fight against waste and their battle for efficiency in order to provide more money for the very beds that the Opposition seek.

Mr. Nicholas Brown

I can answer that now. We do not support the Government's reforms, and we do not support their waste either.

Lady Olga Maitland

The Opposition say that they do not support the reforms, but by the same token they try to take away the opportunity to succeed and provide more for the patients.

Perhaps it would be a good idea if I told the House a little more about the successes that my constituents experience. I have in Sutton the St. Helier NHS trust. It is a proven success. It has made achievements that are well worth noting. Let us take waiting times for an operation. Now, 60 per cent. of our patients are treated within six months. The vast majority wait only nine weeks for a non-urgent out-patient appointment. As everyone knows, urgent appointments can be made within days or, indeed, hours if necessary.

Let us consider the success that we have achieved in hip replacements. Now, no patient need wait a day longer than six months. Let us consider gynaecology. No woman need wait longer than six months for treatment. Let us consider treatment for the eyes. No patient need wait even as long as six months. Often patients are treated within four months. Let us consider the success of day surgery. Now, 50 per cent. of non-emergency cases are treated as day cases. That is the result of modern medicine and techniques.

Five years ago, 20 per cent. of cases in the ear, nose and throat department in Sutton were day cases. Today we get through 60 per cent. of cases as day cases and more people are treated as a result. Let us go back for a moment to the patients charter. Does not the House think that it is marvellous that a patient can now expect to be seen within half an hour of arrival in out-patients? In my St. Helier hospital, 90 per cent. of patients are seen almost immediately.

What about accident and emergency departments, which have been so run down by the Opposition? At my local A and E department, 90 per cent. of the patients who turn up are assessed within five minutes. The nurse makes the initial assessment, reassures the patient and the whole system is put in motion. That is a tremendous advance. There is no longer that sense of fear, not knowing and not getting immediate help. My hospital trust is aware of the pressures at the A and E department and has managed already to allocate resources for a further 25 beds as a result of our efficiency reforms in that department. Curiously, we have the resources for an A and E consultant, but no consultant has come forward for the post. I find that a sad reflection.

Let us consider the success that we have had in children's medicine, which is an important area. Since the children's hospital was moved from the old Queen Mary building into St. Helier's, there is no doubt that children in Sutton have a much better environment in which to be treated. They no longer have to suffer the experience of being moved from one ward, loaded into an ambulance and taken to another building for an operation. Now they will be treated entirely on site. That gives the doctors more time for patient care and enables them to waste less time travelling around.

As a result of the revision of our management of child care, we now have an intensive care bed for children. The children are taken care of by dedicated paediatrically trained nurses. Such successes in Sutton are appreciated by my patients. Why cannot the Opposition bring themselves to admit the successes that can take place within the management of an NHS trust?

Mr. Peter Ainsworth (Surrey, East)

Is my hon. Friend aware of the similar chronicle of achievement at East Surrey hospital, which is not too far away from St. Helier hospital? Does she agree that the rationalisation of health care within central London frees up resources and that hospitals such as St. Helier and East Surrey on the edge of London stand to be prime beneficiaries?

Lady Olga Maitland

I could not agree more with my hon. Friend. He is right that, when we re-examine the concentration of health services in the centre of London, it is appropriate that we recognise that there has been a depopulation of the centre and movement to outlying areas. Furthermore, patients no longer want to travel into the centre of London when they can receive excellent service and treatment close to home.

Another success in St. Helier hospital is in the provision of diagnostic equipment. We now have the most up-to-date diagnostic equipment that any hospital could wish to have. We have a new magnetic resonance imaging scanner and we are ordering a new computerised tomography scanner. With that combination of diagnostic equipment, the hospital will be in the world class in providing services for patients.

Let us contrast the success of medical care both nationally and in my constituency with the gloom, doom and fear-ridden material that has been fed to us by the Opposition. I find it stunning that the Opposition should seek to use what I can only call the Chinese water treatment. They believe that if they give people big, bad news often enough, people will believe that it is true. Every time that I am out on the doorsteps in my constituency, I ask people, "How are you getting on? What are your worries? What are your concerns?" They tell me that they are worried about the health service. I ask what experience they have had that upset them. Then they say, "Oh no, I have been well treated. I have an excellent doctor. I had wonderful treatment in the local hospital. The doctors were dedicated. The nurses were kind. I came home and I am now fit and well." I ask why they feel worried. They say, "It is what the politicians say on television."

It would be more appropriate if the Opposition stuck to honesty and the truth and acknowledged success when it happened. Such success is abundant and widespread. It does not help patients if they hear endless scaremongering stories that create a tremendous amount of nervousness and fear.

I shall give the House an example. Hon. Members have only to look at the Opposition motion. In the first line, they refer to a "crisis". There is no crisis in the health service when it is moving along with the punch, the power and the impact of investment and resources. What do they mean by that?

The Opposition also keep talking about failure. There is no failure when more patients are being successfully treated than ever before. It would be more worth while if the Labour party was a little more honest about what its plans would be, should it ever have the opportunity to run the country. Thankfully, the country will never vote for Labour.

I do not believe that the patients, about whom the Opposition say they are so worried, have any idea that Labour plans to put our medical care under political control. The Opposition want to abolish GP fundholding and break down national health trusts, and put them under the local authorities and town hall politicians. As a patient, I would not want my medical future to be controlled by town hall politicians—certainly riot by socialist ones.

Thank heaven a Conservative Government are taking care of the health service and that there is not a hope in hell that the Opposition will ever take over.

6.20 pm

Mrs. Bridget Prentice (Lewisham, East)

Tomorrow night we shall be debating Third Reading of the Health Authorities Bill. That Bill offered the Government the opportunity to set up a strategic health authority for London, which would have gone a great way to help to resolve the crisis in London's health care. Such an authority could have monitored health care throughout London, co-ordinated activity and avoided the duplication of services to which the Secretary of State referred. It could have targeted resources and developed a coherent health strategy for the capital, which would have benefited the people of London. The Government lost that golden opportunity because they do not listen, not only to the Opposition, but to the people of London.

It was interesting to hear the hon. Member for Sutton and Cheam (Lady Olga Maitland) say that people did not come to her with health care problems. In the past year, more than 60 people have come to my surgeries to complain about aspects of London's health service. If that were duplicated throughout every London constituency, it would add up to about 60,000 people with complaints about what is happening to them and to the health service. It might be useful for the Minister, and through him the Secretary of State, to hear a few examples.

A Miss Beirne was admitted to Lewisham hospital in May 1994 for two hip replacement operations and was given a blood transfusion on admission, in preparation for surgery. Her operation was due to take place within a week or two. Six weeks later, she was still in hospital and had not had an operation. She spent more than eight weeks in hospital for an operation that should have taken no more than two. The hospital said that it was a painful decision when the surgeon had to choose on which cases to operate.

Mrs. Jean Anderson, a 78-year-old pensioner, suffered a fall in her home and fractured her leg. She was released into the care of her frail 80-year-old husband. No attempt was made to give her any form of care or back-up such as a home help. Thirteen days passed without any contact from medical services in the form of aftercare or otherwise. Mr. and Mrs. Anderson were left to fend for themselves and, not surprisingly, Mrs. Anderson's health deteriorated dramatically. Her son contacted Lewisham social services, which offered assistance and, finally, visits from a community physiotherapist and a district nurse were arranged, but she collapsed and died at home less than 24 hours later.

In a letter to me from the community health council, the acting chief officer said: Her chances of surviving would have been increased immeasurably if she had been receiving social, medical, nursing and physiotherapy support. She received none of those.

I mention that case because the Health Secretary suggested that there was sufficient aftercare and enough beds for elderly patients. The "London Monitor", published by the King's Fund, states that there is a severe shortage of residential beds for the care of elderly people, which is not compensated for by the greater than average number of hospital beds in the capital. London has 5 per cent. more hospital beds for acute and elderly care, but 30 per cent. fewer residential care beds for the elderly. The chief executive of the King's Fund said: The complexities of the health care system in London require a high degree of co-ordination if change is to be achieved without paying a very high price in human terms. It is not only patients, or even nurses, who come to my surgeries to talk about the state of the national health service. Two weeks ago, a consultant neurosurgeon sat in the waiting room of my surgery for more than an hour because he wanted to talk to me about the state of the health service in his hospital. It comes to something when a consultant neurosurgeon has to queue up to see his Member of Parliament to explain the sorry state that the health service has reached in London. He said that the internal market was falling considerably short of being a "free market" because of the substantial financial distortions. He told me about the interminable forms that he must fill in whenever he wants to refer a patient. He now employs two secretaries when previously he had none. He told me that competition in health care has resulted in such problems that the free exchange of information has all but disappeared, which is having a negative effect on patients. He also said that the NHS collects the most user-friendly, rather than the most accurate, statistics. One of his colleagues logged 36 appointments for eight patients. For statistical purposes, that was deemed to be 36 patient episodes and, therefore, 36 patients.

I am a great fan of "Coronation Street" and I try to watch episodes whenever I can. I do not expect, and nor do my constituents in east Lewisham or Londoners, expect to be considered as episodes like a soap opera. It is a contemptible device, by which the Secretary of State can pretend that the health service is treating more people when it is not.

I hope that the Secretary of State will listen to the Opposition, to patients in London, to nurses, to neurosurgeons and to the other staff of London hospitals. If she cannot listen to them, perhaps she will listen to the editorial of the Evening Standard today which says: Of course there are national problems with the NHS reforms; in London however these are aggravated by dogmatic hostility to the teaching hospitals, chronic underfunding and a profound inability to appreciate the scale of problems unique to a capital city. There is no room for complacency. This is an urgent situation which calls for acknowledgment and amendment from Government. Let the Secretary of State for Health listen for once, not merely to us, but to the people of London and to London's newspaper, which held such a wonderful conference at the weekend. It explains today exactly why this debate is taking place—because of the crisis in health care in London.

6.27 pm

Mr. Jim Dowd (Lewisham, West)

I shall try not to delay the winding-up speeches too long. As the motion makes clear, more than anything else, there is a crisis of confidence in health care in London, especially in south-east London, and I am delighted to follow my good friend, the hon. Member for Lewisham, East (Mrs. Prentice).

I was a member of the area health authority, as it was then, for Lambeth, Lewisham and Southwark in 1976 and went on to be a member of the successor district health authority—it was disbanded in 1990—until I had to leave for having had the temerity to be an elected member representing Lewisham council. When I first joined the area health authority, there were at least 16 hospitals in Lambeth, Lewisham and Southwark. Today, there are four. At that time, there were six hospitals in Lewisham alone—today there is one.

As a member of the district health authority, I was deeply involved in the planning of what became known as Guy's phase 3—Philip Harris house, which has been mentioned. I took great pleasure in imagining that, one day, it would serve the needs of the people of south London and much further beyond in the ways for which it was designed. That will not happen now.

Trusts in south-east London need to be rebuilt. We suffered the first of the flagship authorities in the formation of Guy's and Lewisham. We were told at the time that Lewisham had to amalgamate with Guy's because it could have no independent existence worthy of the name and the matter was a fait accompli. The result of the consultation that took place was overwhelmingly against the creation of that trust, yet no notice was taken of it and the flagship set sail.

The Tomlinson report, which was merely a cover for the fact that, left to themselves, the market reforms would have severely damaged health care in inner London, then suggested that the Lewisham and Guy's trust could be broken and Lewisham could happily find its own way in the world as an independent trust. It said that Guy's needed to erect a new flag of convenience and amalgamate with St. Thomas's. If Lewisham did not have a secure future on its own in 1990, how could it have one in 1993? Either way, somebody was telling the people of south-east London less than the truth. Although the result of a consultation on the Tomlinson report was overwhelmingly against the setting up of a Guy's and St. Thomas's trust, once again that view was tossed to one side.

The consultation on the latest plan closed last Friday. Most people fear that it will lead to the closure of Guy's hospital in all but name and that all its services as a district general hospital will be extinguished. South-east London needs that district general hospital and the expertise and excellence that Guy's has come to represent. I implore the Secretary of State to make this a genuine consultation exercise, to listen to what people say and to consider the alternatives. Nobody says that nothing at Guy's must change, but that part of south-east London needs four district general hospitals to serve the community.

We need only look at the pressure that already exists at the accident and emergency departments of Guy's, King's, Greenwich and Lewisham, made worse by the closure of both Bart's and the Brook. The Brook hospital estimates a 20 per cent. increase in the pressure on the accident and emergency departments in surrounding hospitals and everyone in the area knows that those departments are not coping even now. Earlier speakers mentioned the fact that people are kept waiting on trolleys. A constituent wrote to me about her father, for whom even a trolley could not be found, who had to sit in a wheelchair for six hours at Lewisham hospital. It is foolish to believe that that position will do anything but deteriorate sharply if we lose the services at Guy's.

To understand that, one need only see the response of clinicians at Guy's about the safety of medical procedures if the A and E and intensive care departments are curtailed. I remember speaking to Peter Griffiths, who was general manager of the district health authority in 1986. He went on to be chief executive of Lewisham and Guy's and was famed for being the man who could drive two cars at once, because that is what he got for the job. He then joined the national health service executive. In 1986, he said that there would be a Government clear-out of hospitals in central London, and his job was to ensure that, whatever else happened, Guy's was not one of them. Sadly, he has failed, but the thrust of what he foresaw was patently clear. We need to save the services at Guy's, not just for the people of south-east London but for its reputation as a research centre, which will be seriously undermined if the watered-down scheme being advanced is proceeded with.

My final point is about the acute trusts and relates to what my hon. Friend the Member for Woolwich (Mr. Austin-Walker) said about accountability. I do not have the same problem with the mental health or primary care trusts, but getting responses to inquiries on behalf of constituents from any of the acute trusts is almost impossible. They respond only after they have been badgered time and again. I have occasionally been forced to table questions asking the Secretary of State to tell them to reply. They do not reply because they know that they are accountable to no one for what they do and think that they can reply, or not, as they see fit.

I shall have to ask the Secretary of State to press the acute service to respond to a letter about a case with which I am dealing. I have had replies, but only once they have been pressed into replying, from the patient liaison manager; the operational and nursing director; the service manager, anaesthetics and intensive care unit service; and the chief executive, all of whom say that they will provide more information at a later date. That shows the insularity that they enjoy in their privileged positions, where they are cut off from the public whom they serve.

Others have said how the London ambulance service is scandalously failing to provide a proper service for the people of London, exacerbating people's problems when they eventually arrive at accident and emergency departments.

Despite Government figures, people know that London's health services are being damaged. That is not because we are spreading bad news to them; on the contrary, they come to us with complaints of what is happening to them and to their families and loved ones. It is patently clear that that is damaging the Government. On Saturday, I received a letter from a woman who said that it took 10 hours for her son to have an emergency operation at Lewisham hospital. She said: I am afraid I never voted for you at the last election, but as my MP I would like you to take up a matter with Lewisham Hospital. She went on to say: I do not blame the doctors or nurses, but I do blame the bloated management and contractors for the poor state of cleanliness in the hospital—I will never again vote Conservative! That is what the experience of the NHS is doing to Government supporters.

The people of London need and deserve better from their health service. Once this Government are out of the way, they will get better.

6.35 pm

Mr. Nicholas Brown (Newcastle upon Tyne, East)

"I will never again vote Conservative" may be the most telling point to be made in this debate, and it has been endorsed by hon. Members from both sides of the House. Apart from the Secretary of State, only one hon. Member has spoken passionately and wholeheartedly in favour of the Government's current stewardship of health care in London. Every other speaker, with differing degrees of emphasis, has referred to his or her fears and concerns and, in the case of Opposition Members, expressed the belief that London's health care is in crisis.

There is a financial crisis and a crisis in secondary care and in accident and emergency services. The promised shift to primary care simply is not happening. There is continuing underdevelopment of community health services, community care and services for the mentally ill. As my hon. Friend the Member for Woolwich (Mr. Austin-Walker) rightly said, the London ambulance service remains a cause for concern, three years after the Secretary of State first said that she would make it her personal priority. My hon. Friend the Member for Lewisham, East (Mrs. Prentice) rightly pointed out—the theme has been echoed by other hon. Members in the debate—that there is neither an overview of services in London nor a recognition of the special and important features that affect health care in the capital.

Condemning the Government's stewardship of the capital's health care services is no reflection on the hard-working public servants in the health service, from consultants to those who clean the hospitals. We do not condemn the work, heart and energy that they put into providing health care in the capital. If they had the Government's support and the necessary resources, they could do a first-rate job, but they have neither the Government's support nor the resources.

I understand that Mr. Roy Lilley has just appeared on the early evening media speaking for the Conservative party about the nurses' pay rise and said: The money is there for the nurses local pay rise; but not for just turning up"— which cannot be compared with Tory Members Parliament. That is not a fair way to deal with nursing staff, whose dedication is much admired on both sides of the House. I understand that the Secretary of State is hinting this evening that she is considering abolishing the pay review body if the nurses do not agree to a 1 per cent. national rise. If the Secretary of State is hinting at that, it is a complete disgrace. If she is not, although time is short, I will happily give way to her now to put all our minds at rest. Frankly, I will happily give way to anyone who can put our minds at rest, but I see that nobody is rising to do so.

I return to the theme of today's debate: the health care crisis in London. At the bottom of the crisis is funding. The allocation of funds to the capital's health authorities, as my hon. Friends have pointed out, has recently been recalculated. The new Government formula appears to benefit outer London at the expense of the inner-city areas. I wonder why. One does not have to think very hard about it. It is quite instructive to place a map of Conservative-held constituencies over one showing the just-losers in the redistribution formula compared with the heavy losers. I have no doubt that it is politically driven and that people who live in the inner cities will lose out. London's 16 health authorities stand to lose £111 million from their budgets over the next five years. That is a cut. As has been pointed out, the biggest losers are in the inner-city areas, with Camden and Islington the hardest hit with a loss of some 14.6 per cent. in purchasing power.

Spending on health care in London as a proportion of total NHS spending has fallen from 20 per cent. in 1988–89 to some 15 per cent. in 1995–96. London has about 15 per cent. of the population, so the Government will no doubt argue that the figures are commensurate, but that is not so, as I hope to show in a moment. The Conservatives do not make the same argument when talking about spending on London's police force. Although the population is the same, spending is 29 per cent. of the national total. Average health authority spending per head for 1994–95 shows London lagging behind Liverpool, Newcastle, Manchester—the other major metropolitan centres. There is also a shortfall in the spending per head on the family health services authorities.

London is a special case, not just because it is the nation's capital, but because it has the nation's largest concentration of inner-city deprivation. Half the entire United Kingdom population of drug abusers is in London. London has 60 per cent. of the homeless population and 75 per cent. of all known AIDS cases. The unemployment rate in inner London is double the English rate. Inner London has three times the English proportion of poor housing and overcrowding. Some 25 per cent. of London's school children qualify for free school meals. Although Conservative Members try to resist the argument, there is a direct link between poverty and health. London boroughs account for seven of the 10 most deprived districts in the UK, as measured by the "Breadline Britain in the 1990s" survey. London boroughs account for 11 out of the 12 of the most deprived districts in the UK, using the Townsend deprivation index.

That has an impact on health. Inner London mortality rates are 25 per cent. above the English average. So London is a special case. The Government's claim to be redistributing resources from secondary to primary care is just not borne out by the facts. They are cutting the budget. The Labour party is calling for a moratorium, a chance to examine again the conclusions of the Tomlinson report. I know that the Minister of State will argue that it is a call for a review of a review, that it is, therefore, time wasting and that we should get on. That is what we are calling for. It is important. If the nation is marching in the wrong direction, it would be better to stop and think again rather than continue marching in that direction, which is the case that the Minister is about to advance on us.

It is our view that the Tomlinson report is flawed. In fairness to Tomlinson, however, he was not asked to examine provision for health care in the whole of London—he should have been—and his report deals only with inner London, and mainly with acute beds. He concluded that London is over-bedded. On that he is wrong. The most realistic figure that I can get—it is substantiated by the House of Commons Library—is that London has 2.5 acute beds per 1,000 of the population. I know that when the Minister responds he will quote a figure of more than four beds per 1,000 of the population, but to get that figure he is including every bed he can possibly find—no doubt including those in the private houses of Conservative Members. It is an exaggeration.

The other argument that Tomlinson addressed is that London has 15 per cent. of the population but 20 per cent. of the expenditure. When one excludes the London allowance and the extra costs involved in the teaching functions of secondary care in London, the comparison is 15 per cent. of the population and 15 per cent. of the resources. There are other reasons why the Tomlinson report is flawed, but time prohibits me from going through them.

In summary, however, the report tries to treat inner London like an "average" English district, which of course it is not. It tries to suggest that increased primary care means fewer hospital patients whereas it may well not. One might well stimulate demand for secondary services by providing primary services. Tomlinson believed that patients from outer London did not use inner London hospitals. That, too, is wrong. Research by the King's Fund has shown that, of half a million in-patients treated in inner London, 150,000 came from outer London or other parts of the country. Tomlinson's calculations also failed to distinguish between the different types of beds—surgical and medical. The crisis is not just one of secondary care, but primary care as well. If the present rate of closure of London's psychiatric beds continues, there will be none left by the year 2000. That cannot be the Government's objective, or the Secretary of State would never be out of the courts.

My hon. Friend the Member for Woolwich (Mr. Austin-Walker) referred to the London ambulance service. Some 37.8 per cent. of ambulances failed to arrive within the patients charter standard time of 14 minutes in London. What on earth is the point of having a charter if the service that is supposed to be supervised by it cannot live up to the results? The London ambulance service is long overdue for a thorough management review, as promised by the Secretary of State three years ago. She told me that it was to become a trust. The trust institutions are the Government's remedy for the problems in the NHS. If that is their preferred remedy, why has it taken so long for it to be put in place in the London ambulance service, where the problems are the most acute?

Mr. Spearing

My hon. Friend noticed earlier that the Secretary of State will not say—I do not know whether the Minister will—whether she will reply factually to the matters that I raised in my two memorandums. Surely the answer is there somewhere, and with the Select Committee on Health examining the matter in its inquiry, which both Ministers have pre-empted.

Mr. Brown

I am convinced that becoming a trust will not solve the problems of the London ambulance service, which seem to be management and technology driven rather than anything to do with the trust structure. If everything is all right in the London health service, why are waiting lists in London the longest in the country? When the Evening Standard sponsors a conference in association with the Association of London Authorities and the NHS Support Federation, why does it talk about the loss of beds, about there being fewer beds than in any other inner-city area, about the increase in waiting lists—just about everything except giving the Conservative party a ringing endorsement? It concluded by passing a resolution, part of which said: We call for an urgent independent inquiry, open to the public, to secure London's threatened health services, teaching and research. That is not an endorsement of the Secretary of State's stewardship, but rather a plea to vote for the motion that the Labour party has tabled today.

6.49 pm

The Minister for Health (Mr. Gerald Malone)

I am grateful to the hon. Member for Newcastle upon Tyne, East (Mr. Brown) for leaving me some time in which to wind up an extremely important debate.

The hon. Gentleman mentioned nurses' pay. I assure him that the Government do not wish to give any impression that they are thinking of abandoning the review body mechanism—an important mechanism set up some 14 years ago, all of whose report recommendations have been honoured. As the hon. Gentleman raised the point, let me also emphasise that there is money in the system to finance its recommendations. I hope that we shall be able to make progress in that regard.

I said this morning—when I was engaged in some broadcasting with the hon. Gentleman—that Labour's policy was a review of a review, and that is exactly what it is: "Let's mark time, let's do nothing." I hoped that this afternoon we might hear some intellectual underpinning for that policy. We heard a number of the constituency points that Opposition Members would be expected to raise in an Adjournment debate, but we were not shown a broad picture of what Labour intends to do about London's health care problems.

We heard no suggestions from Labour Members to deal with the over-provision of specialties and the future of medical education in London. We were not told whether they endorsed the movements that were taking place in the context of our policies; they said nothing about the way in which they would tackle the challenges posed by new technology to the provision of acute care in the city, and how rationalisation could take place in the light of such developments.

I expected the debate to give the right hon. Member for Derby, South (Mrs. Beckett) an opportunity to address these matters anew. After all, she comes relatively fresh to her portfolio, and—as Conservative Members know—she comes to it refreshed by a vigorous campaign for the Labour party leadership. She should be in full flow, exhibiting the drive that she exhibited during that campaign in her examination of the policies. I wondered whether, between that time and now, the right hon. Lady would screw up her courage sufficiently to secure a positive policy from her party. She tells us that she and her hon. Friends have looked at the matter in the round, consulted widely and called for a moratorium. I do not think that that suggests that a great deal of thought lies behind what they are saying.

Mr. Nicholas Brown

Will the Minister give way?

Mr. Malone

If the hon. Gentleman will excuse me, I shall move on.

I was about to say that it was interesting to note the contrast between what the right hon. Lady said and what was said by the hon. Member for Southwark and Bermondsey (Mr. Hughes), who at least conceded that movement was needed on all these fronts and that it would be wrong to arrange a moratorium and yet another review. When asked this morning about the time scale of the review, the hon. Member for Newcastle upon Tyne, East said that the review and moratorium would both take place when Labour was in government, "in perhaps two years' time": I dispute that. In any event, organising the review and moratorium would doubtless take some time. Even if Labour achieved office, it would be committed to a "do nothing" policy for London until the end of the century. It would simply fiddle while London's health stagnated.

Mr. Nicholas Brown

The Minister is having fun with what he parodies as our policy, but he is not telling us much about his own. We are merely asking the Government to stop and think. They are going in the wrong direction. We are saying, "Do not carry on—stop and think."

Mr. Malone

What London's health care needs is for a Government to act on the basis of information before them, and a positive agenda of bringing about change. I shall say more about that shortly.

The right hon. Member for Derby, South had a choice when she embarked on her present responsibilities. She could have played a constructive part in the on-going debate about what should happen to London's health care, or she could have adopted the more fashionable course and joined the "London luvvies" campaign. They attend every demonstration; they come fresh to the scene, and then depart pretty quickly. I am sorry to say that the right hon. Lady seems to have jumped on to the fashionable demonstration bandwagon, rather than contributing to a constructive debate.

Much has been made about whether there has been a real transfer of recourse to primary care. The answer is that there has been, particularly through the London implementation zone initiatives: they involve numerous projects that have improved health care substantially in hon. Members' constituencies. I have seen quite a few of those improvements. I visited the constituency of my hon. Friend the Member for Croydon, North-East (Mr. Congdon), and observed the results of the donation of £30,000 to a mobile unit in the area. That and the provision of £118,000 for community dental services in Hackney are just two examples of many that are being supported by the London implementation zone initiatives—together with the £170 million in capital expenditure on primary care that is taking place over six years.

Earlier this week, I was pleased to be able to announce a £10 million education programme for primary care in London. Such initiatives will continue as primary care improves—and it is vital that that improvement takes place.

During the debate, we heard a number of suggestions about when the need for a change in London's health care originated. In fact, it happened rather longer ago than any hon. Member suggested. I can provide a quotation that underlines what is being done for London's health care extremely well: Never think that you have done anything for the sick of London until you have nursed them in their own home". That is precisely the context in which we are moving care from the acute sector into the community, closer to people; but the quotation is not from Tomlinson or Acheson, but from Florence Nightingale in about 1880. She understood exactly what was wrong with centralised services that were not serving the community properly.

When the health care debate was well under way, the King's Fund said: The status quo is not an option, because Londoners need a first class 21st century health service system, rather than a decaying 19th century one. The question is whether change can be managed, and whether transition can be given an impetus by Government. That is what is happening now, enabling the configuration of health services in London to meet the needs of Londoners.

However, the debate is also important to those who live outside London. It cannot be right for a single part of the country—no matter how much it may say that it deserves resources—to take up an unfair allocation. There has been considerable discussion of hospital beds today. The hon. Member for Newcastle upon Tyne, East is right: I shall cite the figure that he expected me to cite. In 1993–94, inner London had 4.2 available acute hospital beds for every 1,000 people; the national average was 2.3. That illustrates that a large management problem is involved in the spreading of resources around London's acute hospitals, and that it is time that it was rationalised.

London now has 43 major acute hospitals, each of which has more than 250 beds. It has far more than any comparable city. It also has far more specialist services, which consume a tremendous amount of revenue and capital resource. They are spread around the city, and need reconfiguration. That is why rationalisation is required—and not in the impossible never-never time scale set out by the Labour party.

As for overall expenditure and commitment to the people of London, district health authority expenditure per capita in inner London is approximately 50 per cent. above the national average. Family health service authority expenditure, however, is approximately 5 per cent. below the national average. That demonstrates the need to ensure that the resource is transferred, over a reasonable timescale.

Time will not permit me to answer a number of constituency points raised by hon. Members on both sides of the House. I shall read the Official Report and if any of the points require an answer, I shall supply one.

Opposition Members suggested that there was no funding for this transitional period. There is continual funding, both for the acute sector and for primary care. I mentioned the London implementation zone initiatives. In addition to that, £65 million of transitional funding is available for the acute sector. I completely deny any suggestion that what is happening is not being properly funded.

The right hon. Member for Derby, South made what she thought was a rather amusing remark about hooligans on the terraces. We are the players on the pitch and the right hon. Lady is the hooligan on the terrace shouting to cause delay. The Opposition are hooligans with the oddest possible slogan. Hooligans usually shout, "Oh, ah, Cantona!" The right hon. Lady has a new one—"Oh, um, moratorium!"—but it will not wash.

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

The House divided: Ayes 229, Noes 282.

Division No. 77]	[7.00 pm
AYES
Abbott, Ms Diane	Campbell, Mrs Anne (C'bridge)
Adams, Mrs Irene	Campbell, Ronnie (Blyth V)
Ainger, Nick	Campbell-Savours, D N
Ainsworth, Robert (Cov'try NE)	Caravan, Dennis
Alton, David	Cann, Jamie
Armstrong, Hilary	Chisholm, Malcolm
Austin-Walker, John	Church, Judith
Banks, Tony (Newham NW)	Clapham, Michael
Barnes, Harry	Clarke, Eric (Midlothian)
Barron, Kevin	Clarke, Tom (Monklands W)
Battle, John	Clelland, David
Beckett, Rt Hon Margaret	Clwyd, Mrs Ann
Beith, Rt Hon A J	Coffey, Ann
Bell, Stuart	Connarty, Michael
Benn, Rt Hon Tony	Cook, Robin (Livingston)
Bennett, Andrew F	Corbett, Robin
Benton, Joe	Corbyn, Jeremy
Bermingham, Gerald	Cousins, Jim
Berry, Roger	Cox, Tom
Betts, Clive	Cunliffe, Lawrence
Boateng, Paul	Cunningham, Jim (Covy SE)
Boyes, Roland	Cunningham, Rt Hon Dr John
Bradley, Keith	Dalyell, Tam
Bray, Dr Jeremy	Darling, Alistair
Brown, N (N'c'tle upon Tyne E)	Davidson, Ian
Burden, Richard	Davies, Bryan (Oldham C'tral)
Byers, Stephen	Davies, Ron (Caerphilly)
Caborn, Richard	Davis, Terry (B'ham, H'dge H'l)
Callaghan, Jim	Dewar, Donald

Dixon, Don	McWilliam, John
Dobson, Frank	Madden, Max
Dononoe, Brian H	Maddock, Diana
Dowd, Jim	Mahon, Alice
Dunnachie, Jimmy	Marek, Dr John
Eagle, Ms Angela	Marshall, David (Shettleston)
Eastham, Ken	Marshall, Jim (Leicester, S)
Enright, Derek	Martin, Michael J (Springburn)
Etherington, Bill	Martlew, Eric
Fatchett Derek	Meacher, Michael
Field, Frank (Birkenhead)	Meale, Alan
Flynn, Paul	Michael, Alun
Foster, Rt Hon Derek	Michie, Bill (Sheffield Heeley)
Foster, Don (Bath)	Michie, Mrs Ray (Argyll & Bute)
Fraser, John	Milburn, Alan
Fyfe, Maria	Miller, Andrew
Gerrard, Neil	Mitchell, Austin (Gt Grimsby)
Godman, Dr Norman A	Moonie, Dr Lewis
Godsiff, Roger	Morgan, Rhodri
Golding, Mrs Llin	Morley, Elliot
Gordon, Mildred	Morris, Rt Hon Alfred (Wy'nshawe)
Graham, Thomas	Morris, Rt Hon John (Aberavon)
Grant, Bernie (Tottenham)	Mowlam, Marjorie
Griffiths, Nigel (Edinburgh S)	Mullin, Chris
Griffiths, Win (Bridgend)	Murphy, Paul
Gunnell, John	Oakes, Rt Hon Gordon
Hain, Peter	O'Brien, Mike (N W'kshire)
Hall, Mike	O'Brien, William (Normanton)
Hanson, David	O'Hara, Edward
Harman, Ms Harriet	Olner, Bill
Henderson, Doug	O'Neill, Martin
Heppell, John	Orme, Rt Hon Stanley
Hill, Keith (Streatham)	Parry, Robert
Hinchliffe, David	Patchett, Terry
Hodge, Margaret	Pearson, Ian
Hoey, Kate	Pendry, Tom
Hogg, Norman (Cumbernauld)	Pickthall, Colin
Home Robertson, John	Pike, Peter L
Hood, Jimmy	Powell, Ray (Ogmore)
Hoyle, Doug	Prentice, Bridget (Lew'm E)
Hughes, Kevin (Doncaster N)	Prentice, Gordon (Pendle)
Hughes, Robert (Aberdeen N)	Prescott, Rt Hon John
Hughes, Roy (Newport E)	Primarolo, Dawn
Hughes, Simon (Southwark)	Purchase, Ken
Hutton, John	Quin, Ms Joyce
Illsley, Eric	Radice, Giles
Jackson, Glenda (H'stead)	Randall, Stuart
Jackson, Helen (Shef'ld, H)	Raynsford, Nick
Jamieson, David	Redmond, Martin
Janner, Greville	Reid, Dr John
Johnston, Sir Russell	Robertson, George (Hamilton)
Jones, Barry (Alyn and D'side)	Robinson, Geoffrey (Co'try NW)
Jones, Lynne (B'ham S O)	Roche, Mrs Barbara
Jones, Martyn (Clwyd South West)	Rogers, Allan
Jowell, Tessa	Rooker, Jeff
Kaufman, Rt Hon Gerald	Rooney, Terry
Kennedy, Jane (Lpool Brdgn)	Ross, Ernie (Dundee W)
Khabra, Piara S	Rowlands, Ted
Lewis, Terry	Ruddock, Joan
Liddell, Mrs Helen	Sedgemore, Brian
Litherland, Robert	Sheerman, Barry
Livingstone, Ken	Shore, Rt Hon Peter
Lloyd, Tony (Stretford)	Short, Clare
Llwyd, Elfyn	Simpson, Alan
Lynne, Ms Liz	Skinner, Dennis
McAllion, John	Smith, Andrew (Oxford E)
McAvoy, Thomas	Smith, Llew (Blaenau Gwent)
McCartney, Ian	Snape, Peter
Macdonald, Calum	Soley, Clive
McFall, John	Spearing, Nigel
McKelvey, William	Spellar, John
Mackinlay, Andrew	Steinberg, Gerry
Maclennan, Robert	Stevenson, George
McMaster, Gordon	Stott Roger
McNamara, Kevin	Strang, Dr. Gavin
MacShane, Denis	Straw, Jack

Sutcliffe, Gerry	Watson, Mike
Taylor, Mrs Ann (Dewsbury)	Wicks, Malcolm
Taylor, Matthew (Truro)	Williams, Rt Hon Alan (Sw'n W)
Timms, Stephen	Williams, Alan W (Carmarthen)
Tipping, Paddy	Wilson, Brian
Turner Dennis	Worthington, Tony
	Wray, Jimmy
Vaz, Keith	Wright, Dr Tony
Walker, Rt Hon Sir Harold
Walley, Joan	Tellers for the Ayes:
Wardell, Gareth (Gower)	Ms Estelle Morris and Mr. John Cummings.
Wareing, Robert N

NOES
Ainsworth, Peter (East Surrey)	Curry, David (Skipton & Ripon)
Aitken, Rt Hon Jonathan	Davies, Quentin (Stamford)
Alexander, Richard	Day, Stephen
Alison, Rt Hon Michael (Selby)	Deva, Nirj Joseph
Allason, Rupert (Torbay)	Devlin, Tim
Amess, David	Dicks, Terry
Ancram, Michael	Douglas-Hamilton, Lord James
Arbuthnot, James	Dover, Den
Arnold, Jacques (Gravesham)	Duncan, Alan
Arnold, Sir Thomas (Hazel Grv)	Duncan Smith, Iain
Ashby, David	Dunn, Bob
Atkins, Robert	Durant, Sir Anthony
Atkinson, David (Bour'mouth E)	Dykes, Hugh
Atkinson, Peter (Hexham)	Eggar, Rt Hon Tim
Baker, Nicholas (North Dorset)	Elletson, Harold
Baldry, Tony	Emery, Rt Hon Sir Peter
Banks, Matthew (Southport)	Evans, David (Welwyn Hatfield)
Bates, Michael	Evans, Jonathan (Brecon)
Batiste, Spencer	Evans, Roger (Monmouth)
Bellingham, Henry	Evennett, David
Bendall, Vivian	Faber, David
Beresford, Sir Paul	Fabricant, Michael
Biffen, Rt Hon John	Field, Barry (Isle of Wight)
Body, Sir Richard	Fishburn, Dudley
Bonsor, Sir Nicholas	Forman, Nigel
Booth, Hartley	Forsyth, Rt Hon Michael (Stirling)
Boswell, Tim	Fowler, Rt Hon Sir Norman
Bottomley, Peter (Eltham)	Fox, Dr Liam (Woodspring)
Bottomley, Rt Hon Virginia	Fox, Sir Marcus (Shipley)
Bowden, Sir Andrew	Freeman, Rt Hon Roger
Bowis, John	French, Douglas
Boyson, Rt Hon Sir Rhodes	Fry, Sir Peter
Brandreth, Gyles	Gale, Roger
Brazier, Julian	Gallie, Phil
Bright, Sir Graham	Gardiner, Sir George
Brooke, Rt Hon Peter	Garnier, Edward
Brown, M (Brigg & Cl'thorpes)	Gill, Christopher
Browning, Mrs Angela	Goodlad, Rt Hon Alastair
Bruce, Ian (Dorset)	Goodson-Wickes, Dr Charles
Budgen, Nicholas	Gorman, Mrs Teresa
Burns, Simon	Gorst, Sir John
Burt, Alistair	Grant, Sir A (SW Cambs)
Butler, Peter	Greenway, Harry (Ealing N)
Butterfill, John	Greenway, John (Ryedale)
Carlisle, John (Luton North)	Griffiths, Peter (Portsmouth, N)
Carlisle, Sir Kenneth (Lincoln)	Grylls, Sir Michael
Carrington, Matthew	Gummer, Rt Hon John Selwyn
Cash, William	Hague, William
Channon, Rt Hon Paul	Hamilton, Rt Hon Sir Archibald
Clappison, James	Hampson, Dr Keith
Clark, Dr Michael (Rochford)	Hanley, Rt Hon Jeremy
Clifton-Brown, Geoffrey	Hannam, Sir John
Colvin, Michael	Harris, David
Congdon, David	Haselhurst, Alan
Conway, Derek	Hawkins, Nick
Coombs, Anthony (Wyre For'st)	Hawksley, Warren
Coombs, Simon (Swindon)	Hayes, Jerry
Cope, Rt Hon Sir John	Heald, Oliver
Cormack, Sir Patrick	Heathcoat-Amory, David
Couchman, James	Hendry, Charles
Cran, James	Heseltine, Rt Hon Michael
Currie, Mrs Edwina (S D'by'ire)	Hicks, Robert

Higgins, Rt Hon Sir Terence	Page, Richard
Hill, James (Southampton Test)	Paice, James
Hogg, Rt Hon Douglas (G'tham)	Patnick, Sir Irvine
Horam, John	Patten, Rt Hon John
Hordern, Rt Hon Sir Peter	Pawsey, James
Howard, Rt Hon Michael	Peacock, Mrs Elizabeth
Howarth, Alan (Strat'rd-on-A)	Pickles, Eric
Howell, Rt Hon David (G'dford)	Porter, Barry (Wirral S)
Howell, Sir Ralph (N Norfolk)	Porter, David (Waveney)
Hughes, Robert G (Harrow W)	Portillo, Rt Hon Michael
Hunt, Rt Hon David (Wirral W)	Powell, William (Corby)
Hunt, Sir John (Ravensbourne)	Redwood, Rt Hon John
Hunter, Andrew	Renton, Rt Hon Tim
Hurd, Rt Hon Douglas	Richards, Rod
Jack, Michael	Riddick, Graham
Jenkin, Bernard	Rifkind, Rt Hon Malcolm
Jessel, Toby	Robathan, Andrew
Jones, Gwilym (Cardiff N)	Robertson, Raymond (Ab'd'n S)
Jones, Robert B (W Hertfdshr)	Robinson, Mark (Somerton)
Kellett-Bowman, Dame Elaine	Roe, Mrs Marion (Broxbourne)
Key, Robert	Rowe, Andrew (Mid Kent)
	Rumbold, Rt Hon Dame Angela
King, Rt Hon Tom	Ryder, Rt Hon Richard
Kirkhope, Timothy	Sackville, Tom
Knapman, Roger	Sainsbury, Rt Hon Sir Timothy
Knight, Mrs Angela (Erewash)	Scott, Rt Hon Sir Nicholas
Knight, Dame Jill (Bir'm E'st'n)	Shaw, David (Dover)
Knox, Sir David	Shaw, Sir Giles (Pudsey)
Kynoch, George (Kincardine)	Shephard, Rt Hon Gillian
Lait, Mrs Jacqui	Shepherd, Colin (Hereford)
Lang, Rt Hon Ian	Shepherd, Richard (Aldridge)
Lawrence, Sir Ivan	Shersby, Michael
Legg, Barry	Sims, Roger
Leigh, Edward	Skeet, Sir Trevor
Lennox-Boyd, Sir Mark	Smith, Tim (Beaconsfield)
Lidington, David	Soames, Nicholas
Lilley, Rt Hon Peter	Speed, Sir Keith
Lloyd, Rt Hon Sir Peter (Fareham)	Spicer, Sir James (W Dorset)
Lord, Michael	Spicer, Michael (S Worcs)
Lyell, Rt Hon Sir Nicholas	Spink, Dr Robert
MacGregor, Rt Hon John	Spring, Richard
MacKay, Andrew	Sproat, Iain
Maclean, David	Squire, Robin (Hornchurch)
McNair-Wilson, Sir Patrick	Stanley, Rt Hon Sir John
Madel, Sir David	Steen, Anthony
Maitland, Lady Olga	Stern, Michael
Malone, Gerald	Stewart, Allan
Mans, Keith	Streeter, Gary
Marland, Paul	Sumberg, David
Marshall, John (Hendon S)	Sweeney, Walter
Marshall, Sir Michael (Arundel)	Sykes, John
Martin, David (Portsmouth S)	Tapsell, Sir Peter
Mates, Michael	Taylor, John M (Solihull)
Mawhinney, Rt Hon Dr Brian	Taylor, Sir Teddy (Southend, E)
	Temple-Morris, Peter
Mayhew, Rt Hon Sir Patrick	Thomason, Roy
Mellor, Rt Hon David	Thompson, Patrick (Norwich N)
Merchant Piers	Thornton, Sir Malcolm
Mills, Iain	Thurnham, Peter
Mitchell, Andrew (Gedling)	Townend, John (Bridlington)
Mitchell, Sir David (NW Hants)	Townsend, Cyril D (Bexl'yh'th)
Moate, Sir Roger	Tracey, Richard
Monro, Sir Hector	Tredinnick, David
Montgomery, Sir Fergus	Trend, Michael
Nelson, Anthony	Twinn, Dr Ian
Neubert, Sir Michael	Vaughan, Sir Gerard
Newton, Rt Hon Tony	Walden, George
Nicholls, Patrick	Walker, Bill (N Tayside)
Nicholson, David (Taunton)	Waller, Gary
Nicholson, Emma (Devon West)	Ward, John
Norris, Steve	Wardle, Charles (Bexhill)
Onslow, Rt Hon Sir Cranley	Waterson, Nigel
Oppenheim, Phillip	Watts, John
Ottaway, Richard	Wells, Bowen

Whitney, Ray	Wolfson, Mark
Widdecombe, Ann	Wood, Timothy
Wiggin, Sir Jerry	Yeo, Tim
Wilkinson, John	Young, Rt Hon Sir George
Willetts, David
Wilshire, David	Tellers for the Noes:
Winterton, Mrs Arm (Congleton)	Mr. David Lightbrown and Mr. Sydney Chapman.
Winterton, Nicholas (Macc'f'ld)

Question accordingly negatived.

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

Question accordingly agreed to.

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

Resolved, That this House recognises that, because of medical advance, shifts in the population and the changing needs of patients, reform of the health service in London is both necessary and long overdue; congratulates Her Majesty's Government for its resolve in addressing the modern needs of people in the capital and the South East, in sharp contrast to the vacillation and evasion of the Opposition; and believes that policies now being pursued have already delivered a better health service for the area, enhancing the excellence of research, teaching and treatment as well as improving local health services in the parts of greatest need.