§ Mr. Roger Sims (Chislehurst)
Thirteen months ago, the Secretary of State for Health announced, in the context of the Tomlinson report, her strategic direction in respect of the future disposition of services on the two sites owned by the Guys and St. Thomass Hospital trust. The trust subsequently made its proposals, which have been considered by the local health commission and the regional health authority and now sit on the Secretary of States desk awaiting a decision. In making that decision, she will be advised by my hon. Friend the Minister for Health, to whom I am grateful for attending this debate to listen to what I and others have to say before finalising his views.
Discussions on how services should be rationalised between the two hospitals predated the report of the Tomlinson inquiry, which considered the provision of medical services in London as a whole. Unfortunately, the administrative and clinical staff of the two hospitals had difficulties in reaching a consensus. I give credit to the Secretary of State for at least seeking to grasp the nettle in making a statement on 10 February 1994, in which she said:We therefore intend to ask the trust to pursue proposals that, over time, will concentrate acute and specialist hospital services at the St. Thomass site.—[Official Report, 10 February 1994; Vol. 237, c. 460.]She went on to propose that Guys should be used almost exclusively for teaching and research.
The reaction to her announcement was immediate: from consultants, some of whom were my constituents; from people living in the vicinity of Guys; and from patients and ex-patients of the hospital, some of whom were also my constituents. Following that, the hon. Member for Southwark and Bermondsey (Mr. Hughes), in whose constituency Guys hospital lies, called together a group of interested people, formed the Save Guys Hospital campaign, and invited the hon. Member for Dulwich (Ms Jowell) and me to join him as co-chairmen.
The campaign management group consists of doctors, nurses, patients representatives, a solicitor, trade unionists and others, of all political persuasions and of none, united in their concern about the hospital. May I record my respect for the work of the hon. Member for Southwark and Bermondsey, who has, primus inter pares of the chairmen, conducted the affairs of a disparate group with considerable diligence and diplomacy, enabling its members to work well together?
The more I became involved with the group, the more I became convinced that the information on which the Secretary of States decision was based was inaccurate and inadequate. My personal concerns—other hon. Members will no doubt express their worries—stemmed from three aspects.
First, the accident and emergency service at Guys is currently much used by local people; other hon. Members will certainly wish to refer to that dimension. In addition, however, there is a commuter population of some 300,000 people who work each day in the City. Inevitably, among them accidents, emergencies and illnesses occur daily, not to mention the possibility of large-scale incidents such as the Cannon street rail crash or terrorist outrages, both of which the City has experienced in recent years. With the Barts service now closed, it is essential that the City has an easily accessible A and E department.
960 Secondly, Guys has a number of important specialist services such as oncology, cardiac, renal, neurology, ophthalmology, and ear, nose and throat, to which thousands of patients throughout south-east London—indeed, south-east England as a whole—are referred by their GPs. For them, Guys is extremely conveniently placed in terms of public transport, as it is literally on the doorstep of London Bridge station and the bus station. Ease of access is important for patients, but equally so for relatives who wish to visit. No other hospital—certainly not St. Thomass—is as easily accessible.
Thirdly, earlier plans for developing Guys included the construction of Philip Harris house, partly funded from charitable sources. It was planned, designed and built to house the specialist services to which I referred, equipped with the latest technology, and has just been completed at a cost of £154 million. It is incomprehensible that it should not be used for the purposes for which it was intended.
May I make it clear that, while the Save Guys Hospital campaigns purpose has been and continues to be to retain Guys as a viable hospital, it is in no sense antagonistic towards St. Thomass? The issue is the most cost-effective allocation of resources between the sites and the distribution of services between the hospitals, which will provide the greatest benefit to patients.
The campaign group examined in detail the facts and figures pertaining to both hospitals and the implications of the Secretary of States instruction. To assist in that analysis, it commissioned KPMG, which produced a thorough report incorporating alternative proposals, which were clinically coherent, carefully costed and involved less capital expenditure. The campaign group drew on that report in submitting its observations and alternative proposals to the hospital trust.
In due course, the hospital trust issued its proposals, which were to close Guys A and E; to bring together most of the specialist clinical departments on the St. Thomass site; to develop a centre at Guys for day surgery and day treatment; and to bring together the medical and dental schools and Kings college on the Guys site. What the trust effectively proposed, therefore, was to close the A and E department at Guys altogether and gradually transfer most specialties to St. Thomass while producing at the Guys site a centre for what was described as planned surgery, which would be without any back-up facilities such as intensive care—a proposition that much clinical opinion believes to be unsafe. By implication, the trust rejected the KPMG plans and the campaigns variation on them, although it did not argue them in detail.
Those proposals then went to the Lambeth, Southwark and Lewisham health commission, which clearly considered the objections that had been made to it. It effectively decided that the proposals should be implemented, but over a period of five to seven years rather than four. Its recommendation was that the A and E department should be kept open until 31 December 1998 and should not be closed until the expansion plans for the Kings, Lewisham and St. Thomass hospital site were in place, until the London ambulance service was meeting acceptable standards and until the programme to improve primary and community care services in Bermondsey, Rotherhithe and north Southwark had been implemented.
961 It recommended that plans to bring together most of the services currently on the two sites on to the St. Thomass site should proceed, as should developing day surgery at Guys, but that such implementation should be spread over a period of up to seven years and that the trust should be provided with additional funds to facilitate that.
When those recommendations were passed to the South Regional health authority, it did little more than endorse them. In a letter to some of my hon. Friends, the Minister says that it did so after detailed consideration, but I question that assertion. The members of the authority were given only a brief summary of the consultation process and its outcome and, in his report to the authority, the regional director advised members thatno credible alternative plans were put forward during consultation.The KPMG plans may well be susceptible to criticism, but to dismiss them by implication as incredible was surely grossly irresponsible. It is worth pointing out that members of the authority were not given an opportunity to study them until the last minute.
The regional director said that the commissions proposal isresponsive to the concerns raised and proposes a timescale which acknowledges local or public anxieties.I hope that the Minister and the Secretary of State will similarly acknowledge those anxieties, which were reflected in the response to the consultation process.
§ Sir John Gorst (Hendon, North)
Will my hon. Friend advise the House on one specific matter? Guys has, to my knowledge, a reputation for being a centre of excellence, mainly because of its pioneering work in many fields—research, development and so on. Is such history and experience transferable from one hospital on the Guys site to St. Thomass, or is there likely to be any loss in the process?
§ Mr. Sims
It was certainly considered by the campaign group. I hope that it is being considered by the Minister and the Secretary of State.
I was referring to the consultation process. In the course of it, a petition raised by the campaign attracted many more than 1 million signatures and was presented to the House a few weeks ago; another, in similar terms, organised by Unison, bore 30,000 names. In addition, 350 individual letters were written objecting to the plans, compared with 23 in support, and 3,000 standard letters of objection were submitted.
Nowhere in the documents is reference made to the reaction from overseas, where there are many doctors who trained as students or postgraduates at Guys. Earlier this week, I handed the Prime Minister a folder containing 184 letters from distinguished clinicians throughout the world expressing alarm and astonishment at the implication of the closure proposals.
I have not sought the debate to suggest to the Secretary of State or the Minister that the recommendations should be rejected in toto and that we return to square one, but I invite him to recognise their considerable implications and to modify them substantially.
962 Is it logical, having accepted that the A and E department at Guys cannot be closed in the next year or two, to say that it is to be closed at the end of 1998? If it is unsafe to close it now, surely it is unwise to specify that it will close in less than four years time. It is not difficult to visualise the blighting effect that that will have on A and E and on other services, which will begin to decline, will lose members from the expert clinical teams there and find recruitment of the best people impossible. Surely it would be sensible simply to say that the A and E department will remain open and work normally and that its future will be reviewed in a few years time in the light of circumstances then prevailing—circumstances that cannot, at the moment, possibly be foreseen.
How can concentrating specialties on the St. Thomass site, at an estimated cost for additional building of £54 million, be justified when Phillip Harris house, already completed at a cost of £154 million and incorporating the latest medical technology for renal, oncology, cardiac and neurology services, is not to be used to the full? Incidentally, if it is not so used, the future of the £25 million charity money donated for the building is, to put it no higher, uncertain.
The proposal is even more difficult to justify now that we know that the United medical and dental school and Kings college London will not need all the space allocated to them at Guys. Surely the space use needs to be re-assessed. What is needed is to devise a technically and clinically coherent and cost-effective solution that would provide specialist services on both sites but with minimal duplication.
The status quo, to coin a phrase, is not an option. Change is inevitable—indeed, essential—but it must be realistic, it must be orderly and it must ensure that the best possible use is made of the two sites, of the existing buildings and of limited financial resources in the interests of those for whom the two hospitals, and indeed the national health service, primarily exist—patients.
I earnestly plead with my hon. Friend the Minister to consider most carefully all that I have said and the words of those who follow me before reaching any conclusions on these difficult and important issues. I thank him for the time and energy that I know he has already devoted to them.
§ Mr. Deputy Speaker
Order. It is clear that many hon. Members wish to speak, so I make a plea for relatively short speeches.
§ Mr. Simon Hughes (Southwark and Bermondsey)
I am grateful for the opportunity to speak and I am grateful to the hon. Member for Chislehurst (Mr. Sims) for requesting, and securing, a debate.
I do not want the debate to sound like a mutual support society, but I thank the hon. Gentleman for all that he has done and for the clear way in which he made the case. Colleagues on the Opposition Benches have been equally clear and supportive in arguing not from rhetoric or from general proposition but about the case.
I know that, since the Minister took over his job, he has been diligent. He has visited the hospital; he kindly invited me to be with him. He has briefed himself about the position, and we are entirely happy that he is doing 963 the proper job of listening before he takes his decision. I have no criticism of him and hope that we are able to help the process.
Indeed—unusually—the process is, in that respect, working properly, in the sense that the commission carried out the public consultation, it reported, it made some recommendations, which went to region, region considered them and added some riders in its covering letter and the matter is now being debated here before a decision is taken. The process is at least being democratised at its last round.
That is very important because, as the hon. Member for Chislehurst said, and as the Minister knows well, it is not a matter of interest only to those who live and work in the neighbourhood of Guys hospital, whom I represent. It is not of interest only to those who have links with Guys, either as staff or as former staff and patients; it is of much wider interest.
I am grateful to many colleagues who are in the House now and in the other place, and to some who are not here, who have expressed their anxiety and support and kept themselves interested and briefed. There is an army of people—parliamentarians present and past, including Health Ministers from both sides of the House—who have ensured that the case for retaining a viable hospital at Guys is made. That is very important.
The public are also sure about that. One of the largest petitions ever presented to the House was delivered a few weeks ago, bearing more than I million signatures. Signatures are continuing to come in, so a supplementary presentation may have to be made to ensure that no ones signature is excluded; several hundred thousand signatures may be added by the time the Minister and the Secretary of State take a decision.
I want to discuss what appear to me to be the arguments around which the matter is now resolving. The recommendations made by the region gave five reasons for the need for change. In relation to four of them I, at least, do not dissent. It is clear that hospital doctors should work in larger teams and see more patients, that junior doctors hours of work should be reduced and that safer care should be provided. That does not mean to say that we should move immediately to large teams of doctors working in a small number of huge hospitals.
One question is whether a very large consolidated accident and emergency department—whether it be situated on the Guys or the St. Thomass site—could cope not only with patient admissions but with on-going treatment once they are transferred. The Minister is aware of evidence that suggests that existing accident and emergency units—including that at Tommys—already have difficulty coping with the number of patients who are treated there. If the department were to be doubled in size, it is at least questionable whether it would be able to cope with the demand.
There is no theoretical accuracy about the correct size for a hospital. There are trends and movements in particular directions, but the advice changes from decade to decade. We thought that cottage hospitals should be abolished 20 years ago, so we moved to more acute care-centred hospitals. We are now returning to the development of community care beds for small operations. We must not believe that medical science and its management is written in stone for generations to come.
964 We must, of course, take account of the fact that advances in medical treatment and technology are changing the way in which hospitals work. I underline the point that the hon. Member for Chislehurst made in that regard. It seems to most people, and certainly to the individuals and charities who donated the money, nonsense to develop a state-of-the-art building in the national health service in a wonderfully accessible location and then either not use it, or not use most of it, for the purpose for which it was specifically built.
As I was going through my papers last night, I came across the leaflet that I was given when I attended the topping-out ceremony at Philip Harris house in July 1981, which features various photographs with quotes underneath. Under a photograph of the Prime Minister, it says:I am delighted to have the opportunity to congratulate all those involved in this exciting venture at Guys Hospital. Philip Harris House will be a significant addition to the already high standard of services available at Guys and in the National Health Service generally.I send my best wishes to Guys Hospital and especially to all those who will be treated and will work in Philip Harris House.I say amen to that.
I hope that many people will be treated and will work at Philip Harris house. I know that most people think that the £154 million—£25 million of which was charitably raised, apart from the money from special trustees—was committed to that concept and to performing that task. Regardless of the other decisions involved, I ask the Minister and the Secretary of State to confirm that Philip Harris house will be a fixed point for both out-patient care—it is very close to London Bridge station—and the specialist care for which it was designed.
This is the logical place to make the further point to which the hon. Member for Chislehurst referred briefly and upon which I shall elaborate. One of the difficulties involved with the decision-making process—having followed the process from the beginning, I entirely understand that difficulty—is that the facts, figures and evidence keep changing. Whatever we think about the Tomlinson report and the way in which Tomlinson arrived at his findings, it is beyond dispute that more statistics and different facts have come to light since the compilation of that report. It is beyond dispute that the evidence in favour of retaining the accident and emergency department at Guys hospital has changed too. It has been sufficiently persuasive to convince the commission that it would be impossible to go ahead with the original plan to run down the service from next year.
Two very significant further late changes have occurred which have not been the subject either of consultation or of detailed deliberation by the commission or the region in addition to all the evidence about accident and emergency patterns of referral. First, the balance of argument appears to be changing in the continuing debate about neuroscience and neurosurgery. I attended the regional health authority meeting, at which I detected that its members understood that circumstances were changing almost literally before their eyes.
Secondly, there is also a hugely important variation in the plans of Kings college London and the medical and dental school. For those who have not followed all the debate, the whole exercise was concocted to try to work out a way of reconciling the academic and research interests of the United medical and dental school—which is in the process 965 of amalgamating with the Kings College medical and dental school if this gains assent—and consolidating various departments from Kings college London. No one has opposed consolidating those departments, but I understand that Kings college has now said that it does not need as much space as it originally thought.
New Guys house, one of the new buildings, and Guys tower, another of the new buildings, together with Philip Harris house, make up the triangle of post-war redevelopment of the site. When Philip Harris house opens this year, the older buildings—such as Hunts house, which no one wants to occupy—can be demolished. If there is a different space requirement for the academic component, some people will have to decide how to use that space in an integrated way before we reach decisions about the rest of the space. The hon. Member for Chislehurst made the point, and I emphasise it, that it is no use arguing in favour of spending £54 million on new building works or on extensive rebuilding when space for the health service is now available because it is not needed for academic use.
I urge the Minister to conclude that, in relation to buildings and capital and plant investment, it is logical to use the newest building, Philip Harris house, and its linked buildings, Guys tower and the new Guys house, not just for out-patient care or for non-urgent admissions from the local community but as back-up, which will be needed if the provision of elective beds and specialist services is to be safe. Thereafter, Ministers must decide the difficult question of which specialties will be located on which site.
The Government must confirm the maximum amount of money that is available. The commission has asked for more money and it is absolutely clear that the Lambeth, Southwark and Lewisham area needs more funding for health care. The Government must agree whether the commissions requested parameters are appropriate and whether the budget total is correct. Having done that, Government should be able to allow the commission and the trust to work out the best disposition of services.
Ministers do not have to worry about the detail of the arrangements; that should not be a matter for central Government. It should be negotiated by the local trust, which was set up by the Government, and by the local commission. The Government should take the strategic decisions, and I think that there are only one or two key strategic questions which Ministers must resolve.
The first question is whether the accident and emergency unit should be approved for closure not before 31 December 1998; and, secondly, how to use the main buildings, including those that will become available. The right decision would ensure that the beds and specialties appropriate to Guys could be consolidated on one site without duplication, while the others appropriate to St. Thomass would be located there. That must be achieved in a cost-effective manner; I am not arguing that we should waste any money at all.
There is a critical point at which a hospital becomes viable or non-viable. The key to its success is the retention of a casualty department and of a significant number of beds for specialty treatment. There is a postscript to that: if a hospital is to be a major teaching and research centre, it is nonsense not to have people treated on the same site as the students and their teachers are located so that students can have the benefit of practical as well as theoretical teaching.
966 I conclude with two requests to the Minister and a short final point. I endorse the point made by the hon. Member for Chislehurst, but I shall put it slightly differently. If the Government were to follow the recommendation of the commission and say that it is necessary to make the strategic decision now that the accident and emergency department at Guys will close no earlier than 1999, that would be the worst of all possible worlds. Nobody believes that it is possible to close it now. Neither the commission nor the region has argued that it is possible.
It may be possible in some years to come, however, to have fewer accident and emergency departments in south-east London, in south London and in London as a whole. I accept that the trend may be in that direction, but if we are to look after people, treat them properly and prevent them from dying, it is absolutely vital that we do not risk their lives and treatment by closing the hospital too early or, equally bad, by announcing now that we can be certain that we will not need the hospital in four or five years time.
Perhaps it is a little mischievous, but I hope it is an accurate parallel to say that, if the Prime Minister and his Ministers say that it is impossible to judge now whether we should join the common European currency in some years time because the circumstances of the late 1990s or the next decade are not predictable, it is equally impossible to argue that we will or will not need an accident or emergency department at Guys hospital in 1999 or the year 2000, because we do not have enough certain clues about what the demand or pattern of referral will be. We do not know what the implications of the closure of Barts or what the pattern of referral around London will be. In any event, in recent years the number of people being referred has gone up, not down.
I ask the Government: please do not make a decision that will produce four, five or six years of blight when it might have to be further revised. Once such a decision has been made, we cannot expect staff morale or requirement to be sustained.
Secondly, it is important to achieve the best possible use of physical resources and consider whether there is a case for a second phase review—in 1998 or later. When the developments at Kings, Tommys, Lewisham and the Queen Elizabeth hospital, among others, have been completed, let us examine the position again. Of course health provision should always be under review, but we should also always ensure that the buildings used for in-patient care have the most clinically coherent patterns of use.
I am not an expert—there are plenty of experts in both hospitals and in other places. The present muddle is based on two simple historical facts. First, it is a difficult set of decisions to make and, secondly—the Minister knows this—the process from the beginning has not been managed in a way that has carried the confidence of those working on both sites. That is a prerequisite to the satisfactory delivery of a solution.
I believe that there is sufficient good will in the staff of Guys and Thomass, in the commission and in local communities to consolidate a sensible pattern of health care delivery over the next four or five years, developing primary care and transferring resources without putting people at risk.
The postscript is this: a paper presented to the commission made it clear that the current proposals actually risked making the health care of people in my part of the world worse. The House should not be asking 967 or allowing the Minister to go ahead with any decision that makes the health care of any part of our community worse, even in the short or medium-term in terms of risk, access or availability.
We have here a golden opportunity for a brilliant development with the best buildings and treatment in the world. It is an opportunity for Ministers to make a bold decision. I hope they do not make a decision that closes down services that not only we may need for many years to come, but also which, once closed, can never be reopened.
§ 12.4 pm
§ Sir Gerard Vaughan (Reading, East)
I shall speak briefly and with an eye on the clock as I know that a large number of hon. Members wish to speak. That does not mean that I do not regard the subject as extremely important. I congratulate my hon. Friend the Member for Chislehurst (Mr. Sims) and the hon. Member for Southwark and Bermondsey (Mr. Hughes) on their contributions to the debate, and I appreciate the difficulties that face the Minister.
One of the things that I have noticed since I have been in Parliament is that British bureaucracy—certainly in our parliamentary procedures—collects together information, reaches decisions and policies and then, when the information changes, finds it almost impossible to change those policies. I suggest to the Minister that that is exactly what is happening over Guys. Practically all the information on which the original decisions were made has now turned out to be either faulty or irrelevant. From the size of the petition and the tremendously effective campaign to save Guys hospital, there is no doubt about the strength of the anxiety about what is happening.
I would like to put four points to the Minister. First, it seems that there has been no consideration of the international implications of what is happening to Guys hospital. We have very few truly international hospitals in Britain and Guys hospital is one of them. Its standing was certainly, until recently, equal to that of the Johns Hopkins in the United States. International status brings a large number of indirect rewards to Britain in terms of clinical excellence and exchanges of procedures and ideas. It is difficult to measure, but it is very real.
In that context, Guys hospital is not only a London hospital; it is certainly not a community hospital. It is a national hospital as well as being international. We would be taking a very sad step in Britain and in Parliament if we were to discount those aspects of what has gone on at Guys.
§ Sir John Gorst
Is my hon. Friend suggesting that, because it is an international hospital, perhaps it would be possible to fund the hospital partly by charging international patients making use of its facilities?
§ Sir Gerard Vaughan
I do not think that the Government have seriously considered that possibility. I raised the international aspect because I did not think that the Government had considered it.
Secondly, it has been mentioned that there has been huge investment in the hospital very recently and it would be scandalous to throw that away.
968 Thirdly, there is also the problem of transferring clinical teams. People who have not worked in a hospital environment probably do not understand—we have had a number of examples in other parts of London—that clinical teams are built up over many years. Not just the surgeon and the theatre nurses, but all the back-up staff have to be trained, including those in the radiology and pathology departments. We have had disastrous examples of trying to transfer specialist teams to other hospitals. It is not possible to pick them up like the pieces on the chessboard and shift them around without examining the chessboard and trying to retain it. My hon. Friend the Minister may not have taken that into consideration.
Reference has already been made to population. We have a huge development in the channel tunnel. As a result of that, the use of Waterloo station and the surrounding area—and therefore St. Thomass hospital—is likely to change radically, but even more so, we know that the use of London Bridge and north Kent will change radically with the development of the London-north Kent links with the new channel rail. That has not been taken into consideration—and, indeed, as has been said, how can we forecast the population changes that may take place in the next few years?
Serious criticisms are being made about the trust. I am not in a position to know whether they are valid, but it worries me to hear that the trust is out of touch, complacent and not receptive to other points of view because it is so certain that it is right. I do not want to do the chief executive an injustice, but at a meeting that I attended the other day he did not seem to understand what modern patient care and clinical services were really about. Admittedly, he has many other issues to consider.
If my hon. Friend the Minister is informed of changes, he should have the courage—I know that he is a man of courage—to take them into account, and re-examine the proposals for one of our greatest international hospitals—indeed, I would suggest, the greatest.
§ Ms Tessa Jowell (Dulwich)
I congratulate the hon. Member for Chislehurst (Mr. Sims) on securing an important debate at a critical stage, when the future of Guys is being decided. I also pay tribute to the efforts of the Save Guys campaign, a remarkably widespread campaign which has brought together representatives of the local community—through the SICK campaign—hospital trade unions, consultants and patients. As has already been pointed out, its cross-party co-chairing means that it is not a political organisation. It has brought together hundreds of thousands of people throughout the country, who signed one of the largest petitions ever received by Parliament and who are united in their appreciation of the history of Guys and their determination to ensure its survival.
My right hon. Friend the Member for Sedgefield (Mr. Blair), the Leader of the Opposition, recently visited the hospital, and my right hon. Friend the Member for Derby, South (Mrs. Beckett), my hon. Friend the Member for Newcastle upon Tyne, East (Mr. Brown) and I did so last week. We were able to see the new developments at Philip Harris house at first hand, and to discuss the position with the Save Guys campaign.
Since the original announcement on 10 February last year that Guys was to be run down, the campaign to save it has progressed by small steps. I pay tribute to the 969 diligence with which the health authority conducted its consultations: that demonstrated its determination to secure the views of local people and organisations. We in the Save Guys campaign were not satisfied that its recommendations went far enough, but even the health commission—which had been given a job to do—had to be persuaded, at the many local meetings that it organised, by overwhelming evidence of the backing for the hospital. It was also persuaded by submissions that it received: I believe that only 23 out of many thousands supported the proposals to run down the hospital.
Let me stress—as other hon. Members have—just what saving Guys means. It means lifting the date for the closure of the accident and emergency unit, and commissioning and putting into use state-of-the-art facilities that hon. Members have already described in detail at Philip Harris house. That should be done now, not immediately prior to closure. It also means maintaining the capacity of a district general hospital, available to serve whatever needs the local population may have. The hospital must have the necessary support to back up its accident and emergency unit and intensive care services. That is what it will take to ensure the survival of a thriving hospital.
As others have made clear, no one is suggesting that the future of Guys, or indeed any other hospital, should be set in stone. Of course the provision of services must reflect changes in the local community and medical advance; apprehension about the proposals is caused by the fact that they are based on belief rather than proven fact about the effectiveness of the alternatives. The work load of the accident and emergency unit has been greatly increased as a result of the closure of the A and E unit at Barts: fairly minor injuries have already had to be referred to Guys because they were not within the scope of the minor injuries unit at Barts.
Recent work by the Kings Fund suggests that there is no evidence that investment in primary care in south-east London has begun to yield any measurable improvement—any reduction in the number of single-handed practices, and access to a wider range of professionals beyond general practitioners. We want alternatives to be put in place, and their effectiveness clearly established, before the future of Guys is put at risk. That is a simple demand, but if the Minister responds to it we shall have proof that he has listened to the many recommendations made, not just in south-east London, but by hon. Members throughout the country.
§ Mr. James Couchman (Gillingham)
Like other hon. Members, I shall be brief. I congratulate both my hon. Friend the Member for Chislehurst (Mr. Sims) and the hon. Member for Southwark and Bermondsey (Mr. Hughes), who spoke very sensibly about a sensitive issue.
I admit to being un undying fan of Guys hospital, not least because my wife—who was extremely ill five years ago with two episodes of cancer—was so well treated in what is undoubtedly—as my hon. Friend the Member for Reading, East (Sir G. Vaughan) has said—a world centre of excellence. It would be a great shame if Guys hospital died by a process of attrition and blight. I agree entirely with the hon. Member for Southwark and Bermondsey that the decision to close the hospitals accident and 970 emergency department would be premature, although there may ultimately have to be a concentration of AED services in south-east London.
I have been involved in health service management since 1974, first as a member of Greenwich and Bexley area health authority, then as chairman of Bexley health authority. During the time that I served them, I bemoaned salami slicing by South-East Thames regional health authority, to concentrate resources on the three big inner-city hospitals—Kings, St. Thomass and Guys. I argued with successive Secretaries of State and Ministers of State for rationalisation, if services in the outer-London ring and beyond were to develop in a way that was fair and proper to its population. I am grateful to Ministers for listening and for voting a £45 million redevelopment of services on the Medway hospital site in Gillingham.
That hospital currently has associate university status with St. Thomass because there are not enough patients at the latter hospital with day-to-day, secondary care illnesses for medical students to gain experience. At any one time on the Medway site, some 40 medical students are gaining clinical experience and training, drawing on a substantial population 35 miles from central London.
The decision in February 1994 to concentrate clinical facilities on the St. Thomass site staggered me. Some facilities at Guys are dreadful. Its out-patients department must be one of the worst, but to abandon the facilities in New Guys house, the tower and Philip Harris house—which I have yet to see—would be a crying shame and would call into question the judgment used. Hunts house, which is dreadful and should be knocked down, could provide a site for additional clinical facilities. I have always wondered how one could concentrate all clinical facilities from the two hospitals on a congested site across the river at St. Thomass, with the problems associated with listed buildings—I believe that they are referred to as the Nightingale blocks—and finding suitable space to develop new facilities to replace those at Guys.
I congratulate again my hon. Friend the Member for Chislehurst on initiating this debate. I hope that the cry from outer London and from out of London—access to Guys from Kent is vastly superior to access to the Waterloo station area—will be heard. There should be a complete review of the decision to run down Guys in favour of concentrating clinical services at St. Thomass.
§ Ms Harriet Harman (Peckham)
I join in the thanks expressed by other hon. Members to the hon. Member for Chislehurst (Mr. Sims) for instigating this debate. I fully support the comments by the hon. Member for Southwark and Bermondsey (Mr. Hughes) and by my hon. Friend the Member for Dulwich (Ms Jowell). The hon. Member for Gillingham (Mr. Couchman) spoke not only of the needs of his constituents, but of the treatment received at Guys by a member of his family. I have had good experiences of treatment at Guys—my three children were born there. The out-patient department may be in lousy buildings, but one receives first-class treatment, in which one can have complete confidence. The same is true of Guys accident and emergency department.
A storm of anger and fear was created by the Secretary of States proposals to close Guys. The Save Guys campaign has done a great job, but no campaign can go anywhere unless it strikes a chord with the public. There 971 is huge public concern locally, regionally and nationally. In my constituency, people have queued in the rain in shopping centres to sign the petition to save Guys because many of them—like me and the hon. Member for Gillingham—are grateful for the treatment that they received at the hospital, and want it to remain in existence. Also, the public are fearful of what will happen if its services are no longer available. My constituents feel anger at the Governments action in threatening that important hospital and fear the consequences if the Government blunder on in the way they have.
There are three large teaching hospitals in south-east London—Kings, St. Thomass and Guys. That may seem a lot, but still people have to queue for beds for non-emergency in-patient treatment. Patients are still told, We had not planned to discharge you until tomorrow but do you mind going now? In fact, right away—someone downstairs is waiting for your bed. Patients get the feeling that they are being discharged before doctors and nurses think that they are ready to leave, just because there is pressure on the availability of beds.
There are also queues in accident and emergency departments. I have referred to the health service ombudsman numerous cases of people who were left on trolleys waiting to be seen. Despite that pressure on facilities, the Government are saying that they want to close one of those three hospitals.
Guys provides much-needed local services to my constituents, a high proportion of whom are unemployed, or on low pay or live in poverty. First-class, high-quality in-patient services are a way of redressing deprivation in inner-city areas. Nothing should be taken away that would multiply the disadvantages and deprivation that are concentrated there.
My constituents and I also recognise that Guys has never been just a local facility but a regional and national centre of excellence. The public vote with their feet. If one asks a mum or dad sitting by a child's bed in Guys where they come from, they may say Canterbury or Maidstone, but they might come from Brighton—referred by their local hospital because it wants to see whether more progress can be made by sending its patient to Guy's. To tell the public that they cannot receive the excellent specialised services available at Guys is dramatically and wrongly to put the cart before the horse.
My constituents also value Guys because they do not have to travel far if something is badly wrong with them. At present, access to regional services and national specialties are on their doorstep. We value the fact that these local, regional and national services are offered by Guys hospital.
Teaching and research are also important. My constituents know, when they go to Guys, that they are at the leading edge of the science of medicine. Even though they may be unemployed people or single parents from council estates, they know that they are getting internationally recognised first-rate services, and they value that enormously. They do not want the Government to mess it up or take it away.
Why are the Government doing this? There is no consensus that it is being done to improve services—the Government have not made the case for that. The amount of money that may be saved is also highly dubious. In 1991 I attended the topping-out ceremony at Philip Harris house. 972 The champagne corks were popping; people said that I was guilty of sour grapes and asked why I was always so gloomy and negative. This was just at the time when the idea of the internal market was being developed. I suggested that the building might look more like an office block when all was said and done. The harbingers of the problems to do with the internal market were already present, even as people were celebrating the topping out of Philip Harris house. It is a scandalous waste of resources—the very opposite of good planning—that the house, with its intensive care unit, should not be used.
Ronald McDonald house has pioneered opportunities for families of children who are acutely ill to stay near them while they undergo long treatment. Anyone who has been to McDonalds for a hamburger and put money into the collection for Ronald McDonald house will be scandalised if the nearby hospital disappears. That is an abdication of all good planning principles.
Charitable money was also raised for Philip Harris house, and charities have often pitched in to help to build the infrastructure that is needed.
The case has not been made, either, for saying that there are too many beds in south-east London. The information to that effect put out by the Government never chimed with peoples experience. I pay tribute to the work of my hon. Friend the Member for Dulwich on the Health Select Committee; she tabled a great many parliamentary questions, the answers to which revealed that it was not sound to allege that there were too many beds in London. Peoples personal experience of the shortage of beds is truer than the Governments inaccurate figures.
One argument says that, when the GP services become truly wonderful, there will be less use of accident and emergency services. I know from personal experience of the A and E department at Guys and at Kings that many people, had they had a first-rate GP service, would not have gone to the A and E unit. When their children are ill in the middle of the night, they know that someone from a deputising service for the group practice will come and tell them that he does not know what is wrong—You had better go to hospital. Knowing that that will happen anyway, people go straight to the hospital. It is therefore to put the cart before the horse to start talking about closing A and E departments.
Certainly, GP services are being improved—I pay tribute to that fact—but they still have a long way to go. If people lack the necessary primary care services, they still need somewhere to go. We cannot just leave them to it, saying that this use is inappropriate.
My metaphor about putting the cart before the horse also applies to community care services. Granted, there has been an effort to improve them, but it is quite wrong to suggest that we can dramatically reduce the number of beds because everything has been sorted out in primary and community care. People know that the facts are rather different.
Everyone is in favour of the sensible organisation of specialist services. We all know about scientific economies of scale—getting people together doing the same thing and seeing as many patients as possible, so that they become experts. No one is asking for the equivalent of a proliferation of cottage hospitals. We want these specialist services, and we accept that they must be organised as rationally as possible. No one wants services to be duplicated—but that is not what we suggest. We are talking about closures and cuts in bed numbers and A and E services.
973 I pay tribute to the staff who, over the years, have treated me and my children and helped us through child births and various childhood ailments. I also pay tribute to the staff for their work with my constituents—it is immensely valued by the people of Peckham. The staffs morale is still high; despite all the to-ings and fro-ings of the Government, they continue to keep their services going and to keep pushing ahead. It is extraordinary, given what the Government have been doing, that they can still recruit people and push back the frontiers of medicine.
I ask the Minister to tell the Secretary of State not to let down my constituents or the people who work in Guys. He must not let down the people of Southwark, or the people in the region who use the hospital, or the people all over the country who need Guys specialties. The Secretary of State must recognise that it has been a chronic and gross error to suggest the closure of Guys. The Secretary of State has got it wrong and must think again.
§ Miss Emma Nicholson (Torridge and Devon, West)
I offer a warm vote of thanks to my hon. Friend the Member for Chislehurst (Mr. Sims) and his colleagues in the Save Guys campaign. I am especially grateful to him for allowing me a few moments to speak this morning. These debates are hard won, and many people want to speak about Guys hospital.
I speak as a parent of a boy patient who has been at the plastic surgery unit since 1991. I brought Amar to the United Kingdom as a guest visitor, and he had 45 per cent. third degree burns. We ran a public appeal to raise money for him and to get surgery offered free or at low cost. Hospitals around the world came forward—in Scandinavia, the USA, Germany and all over the United Kingdom. Why did we choose Guys hospital? Only Guys was able to give me costs and budgets. I learned then that it was the flagship of the Governments most crucial and necessary health reforms.
Sir Philip Harris, chairman, who later gave so much money for the house named after him, explained to me what the hospital could and could not do. Most important of all, the plastic surgery team, comprising Tony Rowsell, John Clark and David Gateby, came forward. With proper costings and budgets, and with some money given by the British public, I used their services.
I became very familiar with the Rothschild children's ward—the long, weary hours watching dying babies, their parents, and the pain of so many people. I watched the mothers smoking all night, waiting and sleeping there. I saw the borrowing of beds and watched the play leaders and the nurses with their tender loving care. There is a classroom at the end of the ward, and visiting hours are critical. In some strange way, all roads and railway lines seem to lead to Guys hospital. I became very conscious of the gratitude that all who use Guy's services feel—gratitude so profound that it is almost inexpressible.
I and other colleagues have also been involved with another case at the hospital. I refer to my right hon. Friend the Member for Chertsey and Walton (Sir G. Pattie), chairman of the all-party parliamentary group for Romanian children; to my fellow trustee, the hon. Member for Blyth Valley (Mr. Campbell); to my hon. Friend the Member for Poole (Mr. Ward), a committee member; and to the hon. Member for Stoke-on-Trent, Central (Mr. Fisher).
974 Guys has been treating a boy called Adrian Vlad, who is doubly incontinent and has suffered from that impossible condition since birth. Twenty operations in Romania had significantly worsened his condition. The stench that he brought with him was unbearable. Surgeons at Guy's gave him a 10-hour operation, which was followed up by the home care of Tony Rowsell and his wife. The boys life has been transformed.
Guys is a specialist hospital, one that happens to be located in south London, and twinned—through its geography, I suggest—with St. Thomass, under a single trust. Therein lies its misfortune, because Guys specialism, as I perceive it, has naturally grown up alongside the provision of a substantial local medical service, the volume and excellence of which seem to have dominated the necessary and present arguments on the proper place of costs and benefits of the provision of primary health care to the local community.
Of course the Government are right to do all within their powers, which in this instance are not just considerable but near total, to persuade the population, not just in south London but throughout the United Kingdom, to transfer to GP surgeries their significant overuse of A and E facilities for minor medical matters that are really of the preventive and GP-curable kind. Indeed, in Exeter recently, during a bank holiday, I saw that more than half the cases in A and E could have been given to the GP the following morning. Perhaps we are dealing with an accident of patient judgment in self-assessment. Can it wait until tomorrow? Can I see my own doctor? That seems to be commonplace. Or perhaps in the United Kingdom we take our professional medical practitioner services too much for granted.
Be that as it may, the A and E figures throughout London are rising fast, and Guy's is no exception. I am grateful to my hon. Friend the Minister for his decision to extend A and E provision for Guy's for a few more years while proper, modern GP health clinics can be constructed. That clears the air to show the real uniqueness of Guy's, which must not be destroyed if we wish Britain to be a world-class force and a leader in medical work.
The reputations that I have found Guys to enjoy internationally, in any walk of professional life, take many generations to earn. It has taken decades of high-quality training and work to have achieved that high position, and Guy's specialists are renowned everywhere. It was both my parental and international experience of Guy's excellence that made me turn to the Minister with my evidence. I thank him most warmly for listening. It is clear that he already possesses the sagacity of Minerva.
I now call on him to display the wisdom of Solomon and cut the trust of Guy's and St. Thomass hospital in half. He is not faced with one baby, one mother and one umbilical chord, but surely with Siamese twins, who are pulling apart and perhaps would work best separately. I believe that they are in drastic need of surgery by the Ministers own legislative hand. I call on him to make Guys hospital an independent trust and to let it assume the excellence of specialism worldwide that it alone can provide.
§ Mr. Piers Merchant (Beckenham)
I am grateful to have the opportunity to contribute briefly to the debate, 975 because the future of Guy's is inexorably part of the future of the hospital system for the whole of London, and that is of great concern to my constituents.
I ask my hon. Friend the Minister to look closely at the new evidence that is available, especially on A and E provision across London, where there are problems, and also at the quite strong argument for maintaining a future for Philip Harris house. I hope that my hon. Friend the Member for Chislehurst (Mr. Sims) will excuse me if I take a slightly different perspective from his, although I pay warm tribute to him for his work as part of the Save Guys campaign. I listened carefully to his speech this morning. I have read the literature that he sent me and congratulate him on winning the ballot for the debate today.
I have no negative feelings about Guy's and I accept that strong arguments were made by the campaign group. The quality of care at Guy's is excellent and it has a tremendous history, but I do not necessarily accept two of the important premises—at least made by some—of the argument: first, that somehow the future of Guy's can be judged in isolation, that it is of merit in itself and whatever happens will not affect other hospitals and other health care in London.
That is not correct. It will do so, because resources are necessarily, and always will be, limited, and the patterns of demand elsewhere will be affected by what is available at Guys. There is a desperate need for resources to be focused into local areas in London, particularly in outer London, where they are deficient, and I would not want to see that in any way prejudiced by decisions being made on the future of hospitals in London. Resources have been retained in the centre of the capital, when there should be a reallocation to the outer boroughs.
Secondly, I do not accept that Guys necessarily has the best access. Of course transport facilities there are excellent, but many of my constituents find it just as easy, if not easier, to get to St. Thomass. The link between Beckenham Junction, the main station in the centre of my constituency, and Victoria is considerably better than the link between stations in my constituency and London Bridge. People can get as quickly, if not more quickly, to St. Thomass, and with equal ease.
It is important that that is considered in the argument. My constituents want—it is their greatest concern—better local facilities. They want to see a greater emphasis on primary care, particularly fundholding GP practices. The £210 million that will be made available in the current three-year period to expand primary care is an absolute priority. I pay tribute to the GPs in my constituency who have been able greatly to expand their provision, particularly Dr. Kenneth Scott, who is a leader in this area and who happens to be retiring this Friday.
My constituents also want a greater emphasis on local, diagnostic, small injuries and consultancy facilities, which can be done at local hospitals. They want to see more investment in a district general hospital, and better A and E facilities in the borough of Bromley, which is where they live and where the greatest demand is. Of course there is a role for centres of excellence and a need for proper A and E provision in the centre of London, where some of my constituents work, but the emphasis must be on reallocating priorities to where the population is principally resident, and that is in outer London.
976 No action is no option. There has been, and still is, an over-concentration on hospital facilities in central London. It is time to get the balance right. It is time to have better provision in outer London, and to an extent that means at the expense of inner London. I accept that. Unfortunately, it is not possible to please everybody all the time and some difficult decisions have to be made.
The worst of all options is to delay further. We have grappled with the problem long enough. We have seen enough uncertainty. We have seen too many suggestions put up only to be pulled down. We now need to see final decisions so that we can get on with the, perhaps difficult, period of adjustment to the new reality, and with providing the best standard of health care for all the people of London.
§ Mr. Nicholas Brown (Newcastle upon Tyne, East)
It is a great pleasure to follow the hon. Member for Beckenham (Mr. Merchant) and, as so often in the past, to disagree mildly with him, and to add to the advice that has been given to the Minister.
I congratulate the hon. Member for Chislehurst (Mr. Sims), not just on securing todays debate but on achieving the tremendous feat of uniting the House behind the case that he is making. I pay tribute to him, to the hon. Member for Southwark and Bermondsey (Mr. Hughes) and to my hon. Friend the Member for Dulwich (Ms Jowell) for their work on the Save Guys campaign. As well as visiting Guys hospital, I have met the campaign team in the House of Commons. I find its case overwhelmingly persuasive. I pay tribute to everybody who is involved in the campaign.
The hon. Member for Chislehurst set his remarks, rightly, in the context of the Tomlinson report, and said, as did many other hon. Members, not least my hon. Friends the Members for Dulwich and for Peckham (Ms Harman), that it is flawed. The more we examine these matters, the more flawed it seems to be.
Tomlinson was based on the assumption that London is over-bedded. The recent work of Professor Brian Jarman, and the points teased out by my hon. Friend the Member for Dulwich through parliamentary questions, show that that is not the case.
It is claimed that London gets 20 per cent. of NHS funding for only 15 per cent. of the population. That again is a flawed assumption. The figures take into account London allowances, teaching facilities and national responsibilities rather than those that pertain specifically just to London.
It is argued that somehow the capital can perform as though it were an average English district. It cannot do that. For a variety of reasons, London is a special case. It has a large transient population, high levels of social deprivation and poverty, large ethnic minority communities, a higher than average prevalence of mental illness and lower than average provision for personal social services. All those factors require special consideration in their own contexts.
The Tomlinson report stated that increased primary care would reduce the demand for hospital services. That assumption is flawed. It is perfectly possible that increasing the provision of primary care will stimulate the demand for secondary services. That will happen as the need for new treatments are discovered by the primary carer. Tomlinson 977 also thought, perhaps based on flawed research, that patients from outer London do not use inner-London facilities. Recent research by the Kings Fund shows that that is also a flawed assumption, and that about 30 per cent. of patients currently using inner-London hospital facilities come from outside inner London.
Tomlinson thought that the location of casualty services was not important. That again is a flawed assumption. Clinicians speak about the golden hour during which it is important to get a person who needs intensive care to the facilities. Therefore, geography is important. I am sure that the hon. Member for Beckenham would agree with that. Although Tomlinson and the Government did not hold that view when discussing the capital in general, they seem to have taken it when discussing St. Thomass hospital and its proximity to Whitehall. The Government should not try to have it both ways, because that does not do the debate a service.
Philip Harris house is an integral part of Guys hospital and it is a modern, state of the art, national health service facility. As the hon. Member for Chislehurst said, it cost more than £150 million. Some of that money came from charitable sources. My right hon. Friends the Members for Sedgefield (Mr. Blair) and for Derby, South (Mrs. Beckett) and I have visited the site. I agree with the hon. Member for Gillingham (Mr. Couchman) that it is interesting to see the facilities. The fact that they are not to be used for the purpose for which they were intended is mind-boggling. It is astonishing that provision for intensive care is to be ripped out and the building used for some other purpose.
I understand that, when the Ministers predecessor visited the site, he looked at the tower block and sent surveyors from the Department of Health to see whether it could be sold for development into flats. That is not a responsible way to treat NHS facilities. Such development would be an act of clinical and financial vandalism. It is inconceivable that any independent review would or could possibly endorse such a decision, and Labour is calling for an independent review. Moreover, that review must not be pre-empted by irreversible decisions to close facilities.
We ask the Minister to pause and think again. He has satirised Labours call for a review of a review but it is better to stop and think again than to proceed in the wrong direction. The Minister should think about what is happening in London and about the special case that has been made for Guys hospital, because Guys is a special case. It is not a question of setting it against St. Thomass but if, because of its proximity to Whitehall, St. Thomass is to be made a special case, that is a national issue and it should be funded as a national consideration and not placed as a burden on local health care
§ Ms Kate Hoey (Vauxhall)
I should not like the House to be under the illusion that the only case for St. Thomass is that it is near Whitehall. As my hon. Friend knows, about 500,000 signatures were collected some two years ago when there was a huge campaign about the importance of St. Thomass, not just as a national hospital but as one serving the local community. I am sure that my hon. Friend did not mean that its proximity to Whitehall was the only reason for St. Thomass being considered as a national hospital, because that is incorrect.
§ Mr. Brown
I was not trying to make the point that that was the only case for St. Thomass. However, when she was announcing her decisions, the Secretary of State 978 for Health paid particular attention to St. Thomass location. Of course there is a strong case for St. Thomass, but there is also a strong case for Guys and that case, which I endorse, has been made in the debate. I do not intend to set the debate in the adversarial context of Guys versus St. Thomass.
As I have said, the case for Guys is overwhelmingly persuasive, and it rests not just on the superb facilities, the renowned history of the hospital and the major development programme that the Minister seems prepared to abandon. Its compact layout makes it an ideal modern hospital, and the building stock is good. I accept the point made by the hon. Member for Reading, East (Sir G. Vaughan) about damage to the morale of staff and patients if the clinical teams are broken up and transferred elsewhere. For all those powerful reasons, I urge the Minister to think again.
§ The Minister for Health (Mr. Gerald Malone)
My response to the debate will certainly have a compact layout. I welcome the debate and I have listened to as many contributions as possible. They have been extremely useful. I place even more congratulations on the shoulders of my hon. Friend the Member for Chislehurst (Mr. Sims). My hon. Friend shakes his head. No doubt that is because he has had so many congratulations that he finds them overwhelming. They were offered not just on his success in the ballot but on the sensible and constructive way in which he produced his arguments and presented his case. I extend that compliment to the hon. Members for Southwark and Bermondsey (Mr. Hughes) and for Dulwich (Ms Jowell).
The arguments are in the public domain. As the hon. Member for Southwark and Bermondsey rightly said, at this point in the consultation process, the matter is being debated in the House. I can give the hon. Gentleman the assurance that he and other Members sought. Of course Ministers will listen carefully to all views, including those expressed in the debate, and not just to those expressed during the consultation process.
I visited both Guys and St. Thomass before consultation commenced. I am pleased to see the hon. Member for Vauxhall (Ms Hoey) in her place. When I visited St. Thomass, she was also there. I have taken every care to ensure that the fullest possible attention has been given to all the matters that have been raised in the debate. I shall continue to do that, and I know that my right hon. Friend the Secretary of State for Health will look carefully at what has been said in the debate before making final decisions.
I have a number of points about the overall aim of our health policies in London. Basically, they are to improve the quality of patient services and the health of Londoners. In particular, they aim to improve family doctor and other community health services so that Londoners may enjoy the access, level of provision and standards of excellence that are common elsewhere.
They will enable hospitals to respond to the changing demands of an aging and shifting population and to the rising expectation and medical advances that we all know. They also aim to preserve and enhance London's international reputation, about which my hon. Friend the Member for Reading, East (Sir G. Vaughan) spoke, for treatment teaching and research by concentrating facilities 979 into high quality centres. I assure the hon. Member for Dulwich that we shall ensure that changes to hospitals are paced alongside improvements in primary care, so that patients will continue to receive the services they need.
I welcome the fact that the process of public consultation has been soundly endorsed in the debate by the hon. Member for Southwark and Bermondsey. I welcome the contributions that he and his colleagues in the Save Guys campaign made to the process. Ministers are concerned that all views will be taken into account before any final decision is made.
As the House knows, my right hon. Friend the Secretary of State is considering the proposals. It would not be proper or appropriate for me to comment today, but I want to emphasise that the proper amount of time is being taken to deal with all the issues before any firm conclusion is reached. The decisions made will be in the best interests of all concerned. Those decisions are hard, difficult, complex and far reaching. Many interests are involved, but decisions must be made and they will not be fudged or shirked.
I welcome the debate as a further opportunity at a vital time to hear and to take note of the views of hon. Members and of all the people whom they represent. Those views will be laid before my right hon. Friend when she finally considers the proposals for change. I know that she will consider—