National Health Service (London)

HC Deb 10 May 1995 vol 259 cc764-858

Madam Speaker

I must tell the House that I have selected the amendment standing in the name of the Prime Minister. I have had to limit Back-Bench Members' speeches to 10 minutes throughout the debate. I hope that Front-Bench Members will exercise some voluntary restraint in their remarks, as, my researches show that 30 Back-Bench Members seek to speak.

4.26 pm

Mrs. Margaret Beckett (Derby, South)

I beg to move, That this House notes the public's concern over the closure of accident and emergency facilities in London, the reduction in numbers of intensive care, general medical and surgical beds, and the now widely-challenged assumptions that underpin the Tomlinson Report; and calls on the Secretary of State for Health to halt the withdrawal of hospital services and to moderate the pace of change in the NHS across London with particular reference to St. Bartholomew's, Edgware, Guy's and Brook hospitals and to refrain from allowing any further bed losses or service withdrawals, until she has re-examined the case for change and reported her conclusions to this House. The Secretary of State has called into question the need for a debate today on the future of London's health service, but two simple examples explain why we do not share her view, When she announced the closure of the accident and emergency department at Edgware general hospital, she said that many of its patients would be treated instead at other hospitals, of which one was Northwick Park. Within the week, a terminally ill cancer patient, Maggie Curtin, was left in pain for nine hours on a trolley in that hospital, in which, the day after, her husband found her dead in bed. The Secretary of State deems Northwick Park able to cope with the extra work load that will come its way when Edgware is closed, yet clearly it is already a hospital in which staff and resources are under intense pressure.

When Bart's accident and emergency department closed, we were told that patients would go elsewhere, particularly to the Homerton. Before that closure, it was pointed out that the Homerton itself had had to stop taking admissions on no fewer than 10 occasions in the period during which Bart's A and E department was at risk because it could not cope with the existing pressure. Nevertheless, the closure went ahead.

Yesterday, in both radio and newspaper interviews, the Secretary of State demanded to know why my colleagues were not praising the Homerton and the investment there. She continued to stress that theme all day long—long after she must have become aware that the accident and emergency unit at that hospital had been closed for 39 hours because it could not take any other admissions, and that a motor cyclist who had had an accident 200 yards from the hospital had to be sent elsewhere.

Nor are those isolated examples. At 10.15 this morning, London's emergency bed service told us that no fewer than 13 London hospitals are at present restricting admissions because of the pressure on their facilities, yet the Secretary of State says that there is no need for a debate in which we can allow hon. Members to explore the nature and the consequences of the Government's decisions about London health care in greater depth than could ever be possible in the aftermath of a statement, when each Member is allowed only one question.

In the most recent debate on London's health, the Opposition called on the Secretary of State to reconsider the proposals initially put out for consultation in the light not only of the responses to that consultation, but of further evidence that was not available when the initial decisions were made. We drew attention to potentially dramatic changes that were still in the pipeline. For example, special health authority hospitals had been subject to the full operation of the internal market for only a month, so no one knew what the effect would be on those hospitals and the number of beds that they could sustain.

There is nothing to suggest that the Secretary of State has heeded either that further evidence or the outcome of the consultation. That is why our motion calls on her to halt the withdrawal of hospital services and to moderate the pace of change … and to refrain from allowing any further bed losses or service withdrawals, until she has re-examined the case for change and reported her conclusions to this House. Those are the views of millions of Londoners who are not convinced by the Government's case and who are calling for those decisions to be genuinely reviewed and reassessed.

We all know that many hon. Members on both sides of the House are deeply uneasy about whether the Government are pursuing the right course. Not all of them have even suggested that they will abstain or vote against the Government tonight, but many of them would be secretly relieved if there were some way to halt the juggernaut that may be carrying them to destruction along with London's health service.

In the debate that we initiated in February before the Secretary of State's announcement, it was noteworthy how many Conservative Members, having ritually abused the Labour party, expressed considerable concern about what was happening in their constituencies. I hope that they are under no illusions about which part of their speeches the Secretary of State took into account. The right hon. Lady has given too much evidence that her ears and her mind are closed to the voices of those whose opinions she does not share.

In that debate, the Secretary of State said that she welcomed the chance to set out her policy for London and the rationale behind it. Frankly, I doubt that. If there is one outstanding characteristic of her tenure at the Department of Health, it is that she has never come to the House of her own volition to advance, explain or defend in debate the policies that she claims are without need of amendment.

As recently as the weekend, the right hon. Lady said that there would be no concessions on the proposals that she announced finally and reluctantly to the House a month ago; although faced with debate and potential defeat, she is now said to be willing to offer some amelioration to the proposals that she believed so recently to be beyond the possibility of improvement.

Therefore, Conservative Members can be in no doubt that any announcement of change today should be carefully scrutinised for its real impact—being designed to get the Secretary of State off the hook for a few hours while leaving their constituents firmly on the hook in the years ahead.

Mr. Jerry Hayes (Harlow)

Will the right hon. Lady give way?

Mrs. Beckett

If the hon. Gentleman's intervention is very brief and does more than reaffirm his loyalty to the Government's health policy, of which I hope his constituents are in no doubt.

Mr. Hayes

As an hon. Member whose constituency has been through the trauma of the closure of two accident and emergency units in West Essex health authority, I know that the closures were deeply unpopular at the time. There were burning effigies in the streets. Harlow has been through that and we now have a £10 million accident and emergency unit that will serve the area well. With her hand on her heart, never mind the party politicking, does not the right hon. Lady accept that, despite all the medical evidence, a review of a review of a review will not help one single patient?

Madam Deputy Speaker (Dame Janet Fookes)

Order. I hope that other interventions will not be as long.

Mrs. Beckett

The hon. Gentleman has not done himself or his colleagues any service. Under the pressure of time, I shall be reluctant to give way again to an hon. Member who makes the same point that he made in the previous debate.

I do not know what the hon. Gentleman's point is. We are discussing today proposals for other constituencies and other hospitals without any suggestion that the impact of those changes will be addressed in the way in which he claims it was in his locality.

There have been long-standing assumptions about London—that it received a disproportionate amount of money for health care and had a disproportionate number of hospitals and beds, which created problems that had to be addressed. Far-reaching change has already occurred. The number of medical schools was formerly nine but is now five. No fewer than 83 London hospitals have closed since this Government came to power in 1979. The total number of NHS beds in London has halved—the number of acute beds has almost halved and the number of non-acute beds has more than halved. There is no dispute among the experts that more beds have been lost since the Tomlinson report.

There has been a slightly unseemly dispute between Professor Jarman and the Department over whether all the beds that Tomlinson recommended should go have gone. I say unseemly because, in the Department's determination to produce different figures, it has taken a different scope of closures and a different time scale. However, there seems little doubt from the most recent Library figures that almost 2,500 beds have gone from the figures on which Tomlinson made his recommendations.

Some people assume that those bed losses in London are a good thing because they are bound to advantage other parts of the United Kingdom. Those happy optimists overlook the fact that what is happening in London is happening elsewhere. The process of change is the same and often just as damaging, whether in cities or rural areas. Decisions are taken in private, with nominal consultation, if any. The end result in every part of Britain is that the pattern of care delivery is changing without local people being fully involved and feeling that they have a say.

Under the present Government, consultation is a word. At most, it is a formal process that the Government endure, usually without much grace. It is not a process during which the Government listen.

Mr. Roger Gale (Thanet, North)

When I was elected in 1983, my local hospital had been neglected by successive Governments for many years, and had been starved of funds as a result of the disproportionate amount of money going to London. Today, my constituency has £24 million-worth of new hospital, which will treat my constituents on site instead of them having to travel to London. I commend the actions of my right hon. Friend the Secretary of State.

Mrs. Beckett

I am not sure what the hon. Gentleman is saying. Is he saying that because there have been improvements in health care provision in his constituency, which we all welcome, health care in London should be destroyed? Is that what he is saying? That is the reality of what is beginning to happen under Government policies.

In our earlier debate, we sought to persuade the Secretary of State to heed not only the further evidence accumulated but response to the consultation process. Hon. Members on both sides of the House sought from the right hon. Lady measured consideration and a measured response. What happened? The conclusions of South Thames regional health authority reached the Department of Health on 16 March. Those of North Thames regional health authority were submitted as recently as 23 March.

The Secretary of State announced her decision on 4 April. That was in stark contrast to the right hon. Lady's response to the report of the clinical standards advisory group on urgent admissions to United Kingdom hospitals, which apparently did not recommend proposals to the Secretary of State's taste. She considered that report for 13 months before she even published it, whereas the closures were agreed after only seven to 10 days.

The right hon. Lady's own recommendations following those proposals seemed to be no more than a ringing endorsement of what was, in all its essentials, the answer of which she first thought. It is a wonder that she did not introduce her recommendations with the immortal words, "Here's one I prepared earlier."

Mr. Alan Howarth (Stratford-on-Avon)

The right hon. Lady's call for a measured response is really a call for procrastination. She is one of the few Labour Members who have served in government. Has she forgotten that that involves making hard choices? Will she acknowledge that throughout this century, a series of reports have made the case for the reorganisation of London's hospital provision? Does she accept that there is widespread admiration for my right hon. Friend's courage in grasping this nettle?

Mrs. Beckett

Yes, I do remember what it is like to make hard choices, and I also well recall that the making of hard choices involves a great deal more than simply accepting proposals that are put before one. The making of hard choices involves exercising a political judgment and saying sometimes, to those who come forward with proposals, "Yes, there is an admirable case in logic for some of what you say, but it is not the right way to proceed." That is what politicians are paid for.

What the Secretary of State has announced are decisions that could irreversibly affect, among other things, the future of Bart's—an institution which, for almost 900 years, has served the people of London. That is not a reason for saving Bart's. If the people it served had all moved away, if people had ceased to travel in their tens of thousands into that area to work, if it had lacked investment to keep it up to date or had lost the teams of clinicians to make it great, no matter for how many hundreds of years it had existed, its future would be bound to come into question. But that is not the position.

I am not entirely sure that I know quite how to express what I am about to try to say to the Secretary of State. We all know—

The Minister for Health (Mr. Gerald Malone)

Do not say it, then.

Mrs. Beckett

This is not a matter for flippancy, and I have not finished with the hon. Gentleman yet, either.

We all know that people's health is bound up with external factors. Poverty, housing conditions and, above all, stress and insecurity, play a large part in affecting their need for health care. Bart's serves some of the most deprived areas of London. The people who live in those communities already face high levels of stress and insecurity. The removal of an institution on which, for generation after generation, they have depended for health care is bound to add to that insecurity. The Secretary of State is not even listening.

The removal of that institution is bound to add to that insecurity. It is bound to have a deep effect on people's emotions in ways that probably neither I nor the Secretary of State—we have not shared that experience—can fully understand. I see no sign at all that the Secretary of State has weighed any of those matters in the balance.

According to the King's Fund, whose initial report promoted the most recent round of changes, what is now needed in London is a comprehensive and full reassessment of London's health needs and provision. I remind the hon. Member for Harlow (Mr. Hayes), who seems to think that none of this needs to be reconsidered, that they are the people who started the most recent process and they now say that it needs a reassessment.

The Secretary of State still talks as if none of that is needed. Her case is that it is unnecessary because the Government are putting money into primary and community health services in London. But that is as if the investment, which we support, had already addressed and dealt with the continuing problems to which the King's Fund is drawing attention.

But in trying to assess the progress of that investment, the King's Fund said: there has been no systematic attempt so far to gather and evaluate the evidence of the impact of the government's initiatives in London. In fact, a detailed comprehensive description of the kind of projects which have been supported is not available. In other words, neither what has been done nor the effect that those projects have had is yet known. Yet it is on the basis of those unknown projects, that unknown impact, that the decisions that we are discussing today are being made.

Mr. Robert G. Hughes (Harrow, West)

Will the right hon. Lady give way?

Mrs. Beckett

I had better press on a little. If I have time later, I shall give way.

The information that is available is not reassuring. Although building up primary care means more than simply increasing the number of general practitioners, it would appear that the hard fact is that the number of GPs in London is falling and that there remain major difficulties in recruitment. For that reason, the Department has been working with the British Medical Association on a package of proposals to encourage recruitment in London. I understand that the Secretary of State has had those proposals for a year without doing anything about them.

Of the GPs who are working in London, a BMA survey showed that 65 per cent. disapproved of the Government's proposals as detrimental. They are calling—the people who are supposed to be delivering the primary health care development that the Secretary of State says will remove the need for these beds—for an increase in the number of hospital beds.

Waiting lists in London are higher than they were a year ago. Even the figures for the last quarter alone, announced by the Secretary of State today, do not show a reduction in the area that covers London. They show a total waiting list of more than 1 million in the south-east as a whole.

London is caught in a vicious spiral, facing the breakdown of an integrated service. Accident and emergency departments are being forced to absorb the pressure as best they can. Increased pressure on A and E departments means more emergency admissions; more emergency admissions mean the cancellation of an increased number of scheduled admissions; those whose admissions are cancelled end up in the A and E department in need of emergency admission—and so it goes on.

According to Casualty Watch, from the Greater London Association of Community Health Councils, in Enfield the A and E department has sometimes been so busy and so full that even people injured in road traffic accidents have had to be seen in the minor injuries department, which is neither staffed nor equipped to deal with such cases. In Newham, children wait for hours for operating theatres to become available. In Redbridge and Waltham Forest, waiting lists are probably the longest in the country. There were more than 10,000 people on the Redbridge waiting list in 1993; by January this year, the figure had risen to nearly 15,000—an increase of 46 per cent.

The London ambulance service faces severe difficulties in coping with a 10 per cent. increase in accident and emergency work. Consequently, every London citizen faced with a crisis that requires the ambulance service must deal with the fact that it can achieve only a 74 per cent. response rate within the prescribed standard.

Mr. Iain Duncan Smith (Chingford)

Will the right hon. Lady give way?

Mrs. Beckett

If I am going to give way, I shall give way to the hon. Member for Harrow, West (Mr. Hughes).

Mr. Robert G. Hughes

The right hon. Lady quoted some of the reports that have been produced. Many reports have been produced about the health service in London throughout the century. Given that all the scientific evidence and all the studies of accident and emergency services have concluded that the reorganisation announced by my right hon. Friend the Secretary of State would produce a better service and save lives, why does the right hon. Lady lack the political courage to back what my right hon. Friend is doing?

Mrs. Beckett

I have no idea on what evidence the hon. Gentleman bases his assertion, but the evidence available to me suggests that he is simply wrong.

At the beginning of the debate, I referred to the closure this week of Homerton hospital. According to the London ambulance service, that is the second occasion on which the hospital has been closed to "blue calls" since the beginning of April. On five occasions during the past five months, different hospitals have advised the service that they are closed to "blue calls", including St. Helier hospital, which was closed for 38 hours in January.

Ministers know that those are not isolated problems, that they are occurring without a winter epidemic and that they are grave. Only today my office received information about two separate and disparate cases that highlight public concern. Yesterday Mrs. Edith Berry was taken to West Middlesex hospital. Her kidneys were not functioning properly, and Parkinson's disease was diagnosed. A bed was finally found for her at 1.30 this afternoon, 20 hours after she was taken to casualty.

To underline our contention that the problems are widespread and exist not only in London, Mrs. Helen Kime has sent me a copy of a letter that she sent to the Minister of State, whose constituency contains Winchester hospital. She writes: On Monday evening"— that is, Monday of this week— at 7.00 pm … we took a friend with a badly broken arm to the casualty department at Winchester general hospital. He was admitted to the Taunton ward and put on the list for the operating theatre the next day. As I write this letter at 11.00 on Wednesday May 10th, 40 hours after his admission, his arm has still not been set. He was left without food or water. He was not washed. If he was a dog, the hospital would be reported to the RSPCA.

Dame Elaine Kellett-Bowman (Lancaster)

What has that to do with London?

Mrs. Beckett

In a not so sotto voce intervention, the hon. Lady asks what that has to do with London. I have pointed out to the hon. Lady and people like her that those problems do not only exist in London, although we are focusing on London's problems today, and that London cannot be sacrificed because every other area in the country will benefit; every area is experiencing the same difficulties.

Against that background, what are the Secretary of State's proposals, particularly for London? She proposes to close world-famous hospitals, and to take even more beds out of use. Let us look at Guy's, because, apart from anything else, it illustrates the need to scrutinise all that the Secretary of State says today very carefully.

A few weeks ago, the Secretary of State said that Guy's accident and emergency department would not be closed for some years, that Philip Harris house would be used for most purposes for which it was intended and that Guy's would continue to provide a wide range of specialist and local hospital services. I am sure that many of those who heard that announcement thought that it meant that Guy's would be saved as they now know it. Answers to parliamentary questions that I have tabled show, however, that in-patient beds at Guy's will be cut from 702 to 112.

The transfer of services to St. Thomas's will not apparently be possible without even more rebuild, expense and disruption to clinical services than was originally suggested. It will still leave empty eight floors of Guy's tower and all 11 floors of New Guy's house, both recently built and in clinical use. I understand that, even if all the developments required to replace at St. Thomas's facilities provided at Guy's were carried through, available space for clinical services would be less than existing space.

Estimates of the cost of that transfer are in excess of £200 million. Suggestions seem to be made that much of that money will come from private sources. Those who make that investment will no doubt expect a return, yet that investment is being made in large part to replace facilities that already exist. Despite what the Secretary of State said last month, it still appears that 18 state-of-the-art intensive care beds are among the facilities provided in Philip Harris house which will be lost. That is on top of the loss of up to 31 existing intensive care beds at Guy's, when everyone knows that there is intense pressure on such beds in London as a whole.

In many ways, that aspect of the proposals symbolises the Secretary of State's failure. When Philip Harris house is handed over, it will include 12 surgical and six medical intensive beds, which, according to contract, will have been equipped with all the most modern purpose-built facilities and equipment. Such beds are needed. Intensive care beds are under pressure everywhere in London, yet the Secretary of State intends to authorise the spending of millions of pounds of public money to rip out and destroy those facilities so that they can be replaced by something else. No matter what the blueprint is to which she is working, and no matter who the experts are who drew up the blueprint, however long ago it was, that makes absolutely no sense.

There is concern about the practical and financial impact of the proposals for Edgware hospital. The money allocated to build up Barnet hospital is, I understand, sufficient for the first third of redevelopment, but London Health Emergency estimates that the Barnet project needs to be at least two thirds completed before it will be practical even to consider going ahead with the proposals for Edgware. That is apart from the question of redeveloping and making changes in transport patterns in the region, to which Conservative Members have drawn attention.

My chief criticism of the Secretary of State is that a pattern runs through all the proposals and all the problems that the Government create. They anticipate the effect of the change that they have decided is desirable. They presume that what they expect will happen, and that the unexpected will either not arise or be insignificant. When the unexpected does happen, such as the increase in emergency admissions, they carry on regardless.

Sir John Gorst (Hendon, North)

Surely the logic of the right hon. Lady's argument is not, as she has already stated, that there should be a pause or a review, but that the closures to which she has referred should be reversed completely and, in my view, for all time.

Mrs. Beckett

The hon. Gentleman will no doubt make his case and that of some of his hon. Friends, but unless the Secretary of State is made to realise the depth of concern about the whole range of her proposals, some irreversible changes will take place. It may or may not be in the area that affects the hon. Gentleman's constituency, or in the constituency of the right hon. Member for City of London and Westminster, South (Mr. Brooke), who represents Bart's, but irreversible change will take place. We believe that no such change should take place without review.

Mr. Duncan Smith

Will the right hon. Lady give way?

Mrs. Beckett

I cannot. I am sorry. I would have given way to the hon. Gentleman, but time is not on my side.

The Government assumed that the new computer system for the London ambulance service would work as planned and they pushed ahead with its implementation. Across the country, day case surgery increases and, as a result of technical change, there is increased throughput of patients, but either no allowance or insufficient allowance is made for the knock-on effects, for the fact that facilities to resolve the problems of people receiving day case surgery are all too often inadequate or non-existent, and for the fact that speedier discharge of in-patients means far greater pressure on wards as everyone still in hospital is at the peak of their need for care and attention.

Beds in psychiatric hospitals have been taken out of use in huge numbers. Over-ambitious anticipation of reduced levels of need has meant that even though the number of beds in the private sector has increased, there is still well above 100 per cent. occupancy in all too many cases. Psychiatrists despair that the facilities required to help them cope with those with a mental disorder no longer exist on a level to meet the need. What is true in all those areas of policy is especially true in spades of the funding of primary care in London.

The Secretary of State's chief argument for the reduction in hospital beds is that the Government assume what almost nobody else now takes for granted—that investment in primary care will reduce the demand for hospital beds. In fact, there is a growing suspicion that by revealing unmet need, it will actually increase the demand.

What no one doubts is that the public have lost confidence in this Government's handling of the NHS—something for which the Secretary of State blames everybody but herself. The public have lost confidence in the Government's competence, their good faith and their ability to listen.

One of the Secretary of State's colleagues recently spoke of her family's history in terms that, for me, evoked the 1914 war rather than the more recent conflict. Her colleague spoke of her in family tradition marching towards the gunfire. I thought that analogy to be more than a little misconceived. If there is a parallel with the experience of that conflict, it is that the Secretary of State, far from being a brave subaltern or even one of the poor bloody infantry marching towards the guns, is the general, safely back at headquarters ploughing on with a doomed strategy and refusing to take any notice of the fact that there is any alternative.

The right hon. Lady claims to have a mailbag full of correspondence supporting her proposed changes to London's health service. However, when we tabled a parliamentary question asking what percentage that was of the total correspondence that she received on the changes, I am afraid she told us that the figures were not available. It probably would not matter if they were, because I am beginning to think that the right hon. Lady's outstanding political characteristic is that she hears only what she wants to hear. Her ears are as closed to other voices as her mind is to other opinions.

I know that many hon. Members in the House today do not support the policies that the Secretary of State is advocating and that if there were a free vote, she would be defeated. Those who do not support her proposals must weigh seriously whether they should support her in the Lobby tonight. She will take no heed—and I suspect that the Government will take no heed—of measured words of caution or of anxieties, no matter how deep, how sincere or how seriously expressed.

If the House wishes to send a message that even the Secretary of State cannot misinterpret or misunderstand, that message must be clear. It must be bold. It must be defeat.

4.57 pm

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

I beg to move, to leave out from "House" to the end of the Question and to add instead thereof: 'noting that the problems of London's health service have been the subject of at least 20 reports in the last 80 years, all of which have come to broadly similar conclusions, believes that a better service for patients lies in implementing decisions and not a further review; commends the Government for its record in investing in modern hospitals, first class specialist centres and primary care and for its determination to take necessary decisions in the long term interest of the Capital's health service and the people of London; and calls on the Government to ensure that the decisions are now carefully carried forward taking due account of concerns that they should be properly paced so that patients continue to benefit from new and better services before old ones close.'. This is a serious debate and a matter of great importance and consequence. It is a subject of, frequently, great conviction and of great emotion, not only for my hon. Friends but, I accept, for Opposition Members and for those whom we serve in constituencies throughout the land. I believe that our task is to achieve a health service worthy of our capital city for the next century.

To argue merely for the status quo is a grave disservice to the future well being of the health service in London. The right hon. Member for Derby, South (Mrs. Beckett) will recognise—or at least she should recognise—those words not as my words, but as those of her immediate predecessor.

Sadly, as the right hon. Lady's speech today has shown, the Labour party has gone downhill since then. What is remarkable about the so-called new party is how it has scuttled away from the sound consensus on the need for change in London's national health service. The right hon. Lady's moratorium is a cop-out. Dithering in Opposition shows why her party would be a disaster in Government. This debate is a cynical and opportunistic piece of parliamentary gamesmanship, and once again shows beyond doubt that Labour will always put party politics before the nation's interests.

Sir John Gorst

rose—

Hon. Members

Give way. [Interruption.]

Madam Deputy Speaker

Order. I wish to hear the Secretary of State. Does she wish to give way?

Mrs. Bottomley

In a minute.

Governments must rise above such tactics. Our task is to take the necessary decisions that the national interest demands. There are no instant answers or scratch-card solutions. It is not a question of a bit more money here or a review there. Those are smoke-screens thrown up by the Labour party to disguise the real questions at the heart of the debate.

Do we want London to continue to enjoy an outstanding national and international reputation for service, teaching and research, or are we to submit to a second-class service? Do we want Londoners to have the most modern and advanced hospitals, or is it more important to preserve every building and site even when they are outdated and ill suited to today's needs? Do we want to bring general practitioners and community health services up to the standards of the best, or is the current patchwork a price worth paying to maintain the hospitals status quo?

These issues have been debated endlessly: For 30 years, reports have been written and schemes put forward for improving medical care and teaching … Everyone who has studied the problems accepts that specialist services are duplicated, too few patients live near the sites in inner London and those in outer London are deprived. Everyone agrees that the first priority is to improve primary care and help GPs. Those were not my words but those of Lord Annan, a distinguished former vice-chancellor of London university. Lord Annan speaks for many.

I pay tribute to the many doctors, nurses, scientists, academics, commentators, the independent specialty review members, the research team members and the patient groups who have prepared and argued the case for change. They believe that the time has come for the Government to stand firm in London's interests. They speak with a powerful and authoritative voice which we all must hear. They believe that we must build for the future, rather than remain fossilised in the past.

It is not just the distinguished academics and eminent doctors who have been calling for change. Those closest to patients know that the services in London are not good enough. We must address change to make sure that we have a capital health service for the people of tomorrow.

Sir John Gorst

I wish to refer to a point that my right hon. Friend made earlier in her speech, when she described the tabling of this debate as opportunism by the Opposition. May I inform her that I sought from the Leader of the House an opportunity for such a debate and remind her that I wish to register my vote against these proposals?

Mrs. Bottomley

I accept my hon. Friend's constituency interest, and I shall say more about the situation in Edgware and Barnet later in my speech.

The Labour party knows full well that, if it ever pretends to be a party of government, addressing change in London is necessary. Many Labour Members are seeing phenomenal and unprecedented investments in their constituencies as we build hospitals near to where people live. For them, today's debate is a piece of outright cynicism and opportunism. I repeat those words strongly.

Mrs. Beckett

Will the Secretary of State give way?

Mrs. Bottomley

No, wait. [Interruption.]

Madam Deputy Speaker

Order. The House knows full well that is up to a Minister or any Member who has the Floor to decide whether to give way or not.

Mrs. Bottomley

rose—

Mr. Andrew Faulds (Warley, East)

On a point of order, Madam Deputy Speaker. Whatever gibberish the Secretary of State wishes to propound today, should she not be called to order? Is there not a long-established tradition in the House—I have been in the House longer than the Secretary of State—that when the leading speaker from the Opposition gets up, the Secretary of State sits down?

Madam Deputy Speaker

Order. The hon. Gentleman may have been here for a long time, but he has still not grasped the point.

Mrs. Bottomley

I shall give way to the right hon. Member for Derby, South in a moment, but I want to get on a little further in my speech first.

There are difficulties and problems, and it is well understood that hon. Members feel close to their constituents and the institutions which have served them over many years. It is inevitable that when we are faced with such complex and fundamental change, great sensitivity is necessary in handling the delivery of that change. But the difficulties and the problems make the case for change even stronger.

The stories and accounts that we have heard of the difficulties in hospitals are precisely because there are many separate units instead of larger units, which are better managed and which co-operate better in handling the ebbs and flows of health care more effectively. Report after report makes the point that we must deliver a health service which is right for the future, and not a service that was right for the past.

Mrs. Beckett

The Secretary of State has repeated today what she has said repeatedly in the past few days on radio and television. She has said that there is something cynical and opportunistic about the Opposition tabling the debate. As her hon. Friend the Member for Hendon, North (Sir. J. Gorst) reminded her, we called on the Secretary of State to provide a debate during which the House could thoroughly assess and thrash out the consequences of the proposals. We have called on her to do that many times in the past, and it is a demand that she has consistently refused.

If the Secretary of State thinks that it is not the purpose of Members of this House or members of Her Majesty's Opposition to provide an opportunity for proposals of this magnitude to be assessed, debated and discussed by people of different points of view, she does not belong in the House at all. That is what we are here for.

Mrs. Bottomley

I totally accept that the Labour party is the natural party of opposition. It constantly criticises and interprets developments in a cynical fashion, but never has any constructive proposals. Those of us who are now seeing the third health spokesman for the Labour party are still waiting for a policy from any of them. "A moratorium", "out to consultation" and "another review" is what we hear. The Labour party does not want to offend anybody, and it never says yes or no. That is always the way forward for the Labour party.

The right hon. Member for Derby, South responded to an intervention from my hon. Friend the Member for Hendon, North in that way—she said neither yes or no. The Labour party will say anything to try to achieve power ruthlessly and cynically.

Several hon. Members

rose—

Mrs. Bottomley

I intend to proceed.

Dame Elaine Kellett-Bowman

Will my right hon. Friend give way?

Mrs. Bottomley

In a moment.

The change must be handled sensitively and it must be properly paced, but there is no serious challenge to the direction of travel. "Go carefully," we are told, "but do not go back". I give my hon. Friends, Members of the House and London patients a strong assurance that there can be no going back. The issue now is not the policy, but the implementation of the policy.

It is the duty of the health service to carry out the decisions with skill, tact and perseverance if the benefits to London and the rest of the country are to come through. I have just written to the chairmen of the two Thames regions to stress precisely that message. Those chairmen, and the health authority and trust chairmen involved, will be held to account for carrying the policies through. They must explain, listen, lead and reassure staff and public alike that the changes will bring tangible and important benefits to patients. That is a message that they welcome. They are committed to working for the future, and not clinging to the past.

Dame Elaine Kellett-Bowman

My right hon. Friend will have noticed that the right hon. Member for Derby, South (Mrs. Beckett) said that if there were a free vote tonight we would not vote in support of the proposals. Should not the right hon. Lady give a free vote to Opposition Members to see how her northern Labour Members vote? They do not want more money for London, but more money for the provinces.

Mrs. Bottomley

As ever, my hon. Friend is acute on matters of health policy.

Sir Teddy Taylor (Southend, East)

While I fully understand the views of local Members of Parliament, will the Secretary of State confirm that the over-concentration of hospitals and spending in central London inevitably mean that other areas in the region are seriously and consistently under-funded? Would it comfort the Secretary of State to know that many of us have a great deal of admiration for her courage in facing up to an issue that has been neglected for years, but only contempt for the Opposition, who pretend that the problem does not exist?

Mrs. Bottomley

I thank my hon. Friend. He represents a constituency where, in the past, constituents routinely travelled to London for care that they now receive at home. It is time to have a better balance of service and funding. London has long had many specialty hospitals, which are duplicated and fragmented and do not deliver the care that we expect for the future. We seek to achieve a balance within London and the home counties.

The result of the changes will be more modern local hospitals that are better geared to meeting the needs of Londoners today and tomorrow. For example, in Greenwich a new hospital—the Queen Elizabeth—will be available to NHS patients from August, bringing services from two other hospitals on to a better site. Neuro-sciences will transfer from the Brook to King's. Close links with the internationally respected Institute of Psychiatry will establish a truly world-class centre of excellence.

Hon. Members will know how strongly I believe that our job is to maintain not only national but international excellence in this country's research and teaching. The Brook hospital will close as it is old, cramped and ill-suited to modern health care. Incidentally, it has no "e" on the end, as the Opposition wrote in their original motion.

Mr. Harry Greenway (Ealing, North)

My right hon. Friend will know of my concerns for the national health service in London, which I have frequently discussed with her. The hon. Member for Newham, South (Mr. Spearing) and I have often raised the issue of the London ambulance service. Is she aware that this morning I called an ambulance for a lady who collapsed before my eyes? It arrived within seven minutes and the lady was in hospital and being properly treated shortly afterwards. Will that be the future pattern for London?

Is my right hon. Friend also aware that, just a few years ago, Labour-controlled Ealing council put £500,000 on the rates of Ealing hospital and other medical or hospital institutions in Ealing, so much did they care about the health service for my constituents—

Madam Deputy Speaker

Order. I have already said that interventions must be brief.

Mrs. Bottomley

My hon. Friend is right about the significant developments in the London ambulance service, which for many years has been a troubled and unsatisfactory service. We now see extremely encouraging progress: better manning and staffing arrangements, clearer leadership and, above all, a better service for the people of London, including my hon. Friend's constituents.

Ms Glenda Jackson (Hampstead and Highgate)

The Secretary of State will know that last year one of my constituents suffered third-degree burns to 40 per cent. of his body on a Sunday. He had to be taken to hospital in a fire engine because no ambulance was available in north-west London. When I drew that case to the attention of the Secretary of State, the letter that I received in reply led me to believe that new ambulances would be provided for that part of London. A subsequent letter has told me that the proposal to cut the ambulance service within my constituency from its present complement of eight ambulances to two is a step forward. I do not regard that as an advance and nor do my constituents.

Mrs. Bottomley

I shall look into the hon. Lady's case. I can inform her, however, that 180 new vehicles are being provided for the London ambulance service and there is a formidable programme of investment. We have long sought better management and leadership of the London ambulance service, which is one of the few services left that has not gained trust status. It is old-style NHS, not the NHS that we have been so keen to put in place.

As well as the changes that I have described, many other hospitals are being strengthened and improved. I challenge the Opposition to admit that their constituents often see the benefits. The hon. Member for Hampstead and Highgate (Ms Jackson) is all too keen to criticise, but we rarely hear about the improvements taking place at the Royal Free hospital or the extra investment. The hon. Member for Islington, North (Mr. Corbyn) never mentions the £2 million spent on his accident and emergency service.

Mr. Jeremy Corbyn (Islington, North)

Will the Secretary of State explain why there was no elective surgery in the Whittington hospital between December and April this year? Why are 3,000 people waiting for operational appointments at the Whittington hospital when she has managed to spend so much money on improving health care in Islington by closing Bart's and the Royal Northern hospitals?

Mrs. Bottomley

Time and again, the Opposition fail to appreciate why it is so necessary to introduce change in London. Waiting times are coming down, but we need larger and better balanced units, A and E services which deliver a high quality of care, and investment in primary care. That is exactly what we are delivering.

Although we hear from the hon. Member for Dulwich (Ms Jowell) about Guy's, she never mentions what is happening at King's—the new neuro-sciences unit, liver unit and magnificent day surgery unit, and the £8 million going into the A and E services. Nor do we hear from the Opposition that by tackling the problems in London we can better help hospitals outside London, which so many of my hon. Friends are concerned about.

Sir George Gardiner (Reigate)

Before my right hon. Friend leaves the subject of constituency interests and loyalties, is she aware of the great irritation felt by many patients outside London at the assumption that any serious case must be treated at a London hospital? She will be aware of all the new regional specialist centres that have been founded in recent years. Will she undertake not to seek to pacify pressure groups from London at the expense of funding for the new centres of excellence throughout the country?

Mrs. Bottomley

My hon. Friend is exactly right. What we need is a national health service which serves patients' interests but does not have its agenda dictated by the patterns of the past.

I wonder whether the hon. Member for Plymouth, Devonport (Mr. Jamieson) will speak on behalf of his constituents. Does he still want them to travel 200 miles from Plymouth to the London Chest hospital for their heart operations, or will he have the courage to admit that the changes in London will deliver a new cardiac unit in Plymouth?

The person who deserves a prize for the ultimate cynicism is the right hon. Member for Derby, South. Did we hear a word from her about the £10 million for the Derbyshire Royal infirmary? Of course not. It is the height of hypocrisy for the right hon. Lady to criticise changes in London when similar concentrations of specialist services are taking place in her constituency along with the development of community services, and her constituents are seeing the benefits.

Mr. Hugh Dykes (Harrow, East)

My right hon. Friend is right to say that Conservative Members do not need advice from the Labour party. When it was last in government, some 60 hospitals a year were wholly or significantly closed down. Does my right hon. Friend appreciate the difference in the complex arguments between central and outer London hospitals and the severe crisis that Edgware General hospital in outer London faces? If its A and E unit is closed down, Barnet General hospital and Northwick Park hospital will be too far away for ambulances to get there in time. Her suggestion of two additional ambulances is insufficient and inadequate. Will she respond to those arguments for Edgware General hospital?

Mrs. Bottomley

My hon. Friend will understand that I have already said that I hope to say more about Edgware General hospital later. I shall refer specifically to the matters that he has mentioned, but he is absolutely right about the Labour party.

The right hon. Member for Derby, South may be an endangered species, as one of the few members of her party to have served in government, but she appears to have forgotten that Government's record, in which I am not surprised that she takes little pride. Sixty hospitals closed in every year that Labour were in office. They cut nurses' pay and cut—

Mrs. Beckett

The Secretary of State has now said two things in an attack on me. The first I find extraordinary. She says that I do not welcome investment in my constituency; of course I do. But why—[Interruption.] I simply add that, when the Derbyshire Royal infirmary, to which she referred, was contacted, it asked where the £10 million was, but we shall not go into that.

I do not know why the Secretary of State should suppose that, because there has been investment in hospitals in my constituency, I should be indifferent to the problems that she is causing in London. That is a peculiar attitude to express.

Secondly, it is untrue that 60 hospitals a year closed under the most recent Labour Government. The figures show that 128 hospitals were built in five years under the most recent Labour Government, compared with 21 under the present Government.

Mrs. Bottomley

We can clarify the figures further at a later time. [HON. MEMBERS: "Oh."] Sixty hospitals closed—[Interruption.] The hospital closure programme of the most recent Labour Government is the least of their record. What about a party that cut nurses' pay, cut doctors' pay and cut national health service spending for the only time in its history? That is what the right hon. Lady—

Mrs. Beckett

Will the Secretary of State give way?

Mrs. Bottomley

No, I have given way quite enough. [HON. MEMBERS: "Give way."] No, I will not.

That is what the right hon. Lady described a moment ago as exercising political judgment. Those of us who worked in the health service at that time remember what that political judgment was like: it was painful for staff and patients, and none of us wish it to be repeated.

Mr. Nigel Spearing (Newham, South)

It is being repeated.

Mrs. Bottomley

That is interesting. The hon. Gentleman said that it is being repeated, but it was a strange use of language because there has been an enormous advance in nurses' and doctors' pay, there has been an improvement in training and, most important, we have opened—not closed, but opened—a new hospital development, on average, every week that we have been in government.

Mr. Jacques Arnold (Gravesham)

Would my right hon. Friend note that we in north-west Kent, which goes for many of the home counties, resent the fact that so many of our constituents have to travel at great inconvenience all the way into central London for treatment, where added on-costs of 40 per cent. apply? That is because resources have always been concentrated on central London. If my right hon. Friend presses on and releases resources to improve the type of centres to which my hon. Friend the Member for Reigate (Sir G. Gardiner) referred, and Darenth Park hospital in my constituency, she will have support for putting health care where people actually live.

Mrs. Bottomley

I share my hon. Friend's opinions, but it is important that the specialty services which remain in London—the tertiary services—should become even greater centres of excellence.

The dilemma is that, as fewer patients come to London, for all the understandable reasons, because of the massive building programme that we have established throughout the home counties, when they do come to London they will expect a level of care and a quality of expertise that is among the absolute best. Only by bringing those specialty services together shall we achieve that excellence. That is what the specialty review said. That is what the academics and the researchers said time and again. That is the reason why we have received such strong support for those proposals from the leaders of the profession, especially those who mind about excellence, not only for the present century, but for the century ahead.

Mr. Simon Hughes (Southwark and Bermondsey)

Will the Secretary of State give way?

Mrs. Bottomley

I will not.

Before I leave the subject of the record of the right hon. Member for Derby, South, it is irresistible for me to remind the House about the cuts over which we have indeed presided—the cuts in waiting times. Five years ago, before our reforms, there were 200,000 one-year waiters in the country. It is interesting that the Labour party sneers when it talks about waiting times because, if one asks people what they think about the national health service, time and again they say that they cannot fault the care that they had, but that they waited too long. We have consistently made waiting time a priority. Yesterday we announced that, instead of 200,000 one-year waiters, we now have fewer than 32,000. That is a splendid and remarkable achievement.

Mr. Patrick McLoughlin (West Derbyshire)

When my right hon. Friend talks about the record of the national health service, for which she is responsible, in Derbyshire, will she acknowledge that not only have new buildings been built at the Derbyshire Royal infirmary but a new children's hospital will soon open in the Derby City General hospital and a brand new hospital has been built in Chesterfield? That is our commitment to the health service and the capital programme, which was cut by the Labour party in Government.

Mrs. Bottomley

Once again, my hon. Friend exactly identifies the issue. The Labour party appears to argue that one can have all the new hospitals, the new developments, the centres, the equipment, the expert staff, without ever closing an old hospital, without ever taking a difficult decision, ducking every difficult problem, pandering to every pressure group. The new Labour party makes Michael Foot's old outfit look like international statesmen.

If we ducked the decisions, the Opposition would have a legitimate cause for grievance, but they know that it is not so, because we are tackling the issues that matter. I have talked about improved hospital services closer to where people live. Improved primary care in London also matters. It matters that the poor, the sick, the homeless and the mentally ill can rely on effective local services to meet their needs.

When the right hon. Member for Derby, South was a Labour party researcher, I was researching in the east end, in Bethnal Green. I know how people in Bethnal Green were deprived of even a moderate level of primary care, of general practice, of the basics of a health service. Yes, there were any number of institutions, but the basics, which must be the essential foundation of a health service, were lacking. I do not take it kindly when the right hon. Lady suggests that I do not know the realities of life in the inner cities, having spent more of my life working in the most impoverished districts in the inner cities than I have in politics, let alone in government.

Mr. Simon Hughes

Will the Secretary of State give way?

Mrs. Bottomley

I shall come to the hon. Gentleman in a moment, when I discuss his area.

Time and again, the Labour party used to urge us to invest in primary care. It does not make that charge so much any more, because we have exceeded the commitments that we promised at the beginning of the process. The King's Fund and Tomlinson recommend investment in primary care. Tomlinson recommended £140 million for primary care. We have invested £210 million in 1,000 or more schemes throughout London—new general practitioner services, modern health centres, community health teams, hospitals at home. That is a great range of provision. When did the Labour party ever do as much for the people of London? When did it ever do anything for the people of London?

What matters is decent community care. It matters that elderly infirm people are well looked after at home or in homely surroundings. Since the publication of the Tomlinson report, we have committed an extra £338 million to London local authorities for social services. The first fruits of that investment are becoming apparent. An extra 200 nursing beds opened in inner London in the past year, another 800 were approved and there are plans for at least 1,000 more. Those are the necessary services to meet the needs of an aging population.

It matters that patients who need emergency care receive it from a well equipped centre, staffed by highly trained doctors and nurses, with all the back-up that they need—not from old, isolated units where care might become a lottery and lives might be put at risk.

A small number of larger clinical teams gives the patient the best chance, each team supported by a greater number of intensive care and specialist beds"— not my words, but those of a doctor who works in one of the busiest accident and emergency departments in the capital, Dr. Howard Baderman, who also advises the chief medical officer on A and E services.

The clinical advice is clear and consistent. No responsible Government could construct a health service disregarding the advice about the way to have the best clinical outcomes from A and E services—the basic and fundamental element in our health service.

When the Labour party cannot attack the argument, it plays on the fears of the vulnerable and the sick and spreads scares, but the public have seen through that. They remember Jennifer's ear: that lost Labour the last general election, and it will lose it the next.

What matters is harnessing new technology to treat more patients to an ever higher standard. Many more patients can be treated without staying overnight in hospital or by their GPs. The new specialist centres outside London, to which my hon. Friends have already referred, mean that patients can be treated locally rather than in London. Health authorities have a duty to plan the level and range of services that their areas need, which must, of course, have an adequate and appropriate supply of beds.

The Government do not have a target for bed numbers. We expect health authorities to balance services to needs, year by year. They must take account of the prevalence of disease, the age structure of the population, the formidable advances in clinical practice and all the other factors that affect the demand for services. Contrary to what is suggested in the motion put down by the Labour party, there has been a significant increase in the number of intensive care beds. As the House is aware, we are now looking again at how we can better manage those intensive care beds. Time and again, the advice is to bring them together in larger settings so that the health service can better cope with the ebbs and flows.

Sir Michael Grylls (Surrey, North-West)

Does my right hon. Friend agree that most of us understand the special constituency interests of those who represent inner London, who are concerned about hospital closures? Despite that, the reform of health care in London is long overdue and the relevant report has been sitting around Whitehall for far too long. Most of us recognise my right hon. Friend's courage in taking up the reform and her determination to see that good health care is provided not only in London but in the provinces, to which a lot of people from London have moved out.

Mrs. Bottomley

I thank my hon. Friend for those remarks, which I appreciate.

It is important to set the record right about beds. We need the right balance. The number of beds closed in recent years does not match that quoted by the right hon.

Member for Derby, South. In the past three years, we have seen a 30 per cent. increase in activity [HON. MEMBERS: "Activity?"] The number of beds in inner London has reduced, but the reduction has been more cautious than the level set out by the King's Fund and it is in line with the Tomlinson proposals.

We have always made it clear that the proposals need to be carefully implemented and monitored. We need to be watchful as we take forward those plans, and that is why the report of the inner London chief executives is so important. It is their duty to ensure that they plan services according to local need and get the balance right. Their report, which was published just the other day, made it clear that what is needed is not more acute beds in total, but a better disposition of specialist and general acute beds, and medical and surgical teams to meet the needs of patients. They have set up an action programme to address the problems that exist. It will provide better bed management, better discharge arrangements and will tackle bed blocking. That programme will ensure that there is better co-operation on emergency admissions.

The right hon. Member for Derby, South referred to Homerton. It has always been the case that there have been ebbs and flows in the pressure on hospitals. Co-operating carefully on those arrangements represents the best way of managing the health service. Not only are there more beds open at that hospital, but a great many more are planned. That hospital will be subject to a £30 million programme. The same is true of Northwick Park, where at least 30 beds have been opened this year and 40 will come through next year. We have identified the need for change in those hospitals and are addressing it.

Ms Diane Abbott (Hackney, North and Stoke Newington)

Will the Secretary of State give way?

Mrs. Bottomley

No.

Ms Abbott

Specifically on Homerton?

Mrs. Bottomley

I hope that the hon. Lady will understand if I do not give way. I have already spoken for a long time and if I do not make progress, hon. Members who want to speak may not have the opportunity to do so. I am sure that the hon. Lady will find an opportunity to speak later.

I must refer to some of the areas that have caused great concern. My right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke) has argued powerfully that the ethos, traditions and culture of St. Bartholomew's should be preserved as services move to Whitechapel. I agree with him. He knows that a task force chaired by Sir Ronald Grierson is examining alternative uses for the St. Bartholomew's-Smithfield site in keeping with its proud past. In addition, a working group led by the Corporation of London has been developing plans for the alternative provision of community services at St. Bartholomew's to meet local needs. Others have suggested that the name of St. Bartholomew's should live on in the title of the trust—I accept that—in practice as well as in spirit. [Interruption.] I am pleased to say that the trust is considering that suggestion and I hope that it will be able to make that announcement soon.

My right hon. Friend and my hon. Friend the Member for Chislehurst (Mr. Sims) have queried the pace of change at the Guy's-St. Thomas's development. During consultation a number of modifications were made. Let me reassure my hon. Friend the Member for Chislehurst that the A and E at Guy's will not close until alternative services are ready to take its place and able to provide better care. Those services include improved primary care, the minor injuries unit and the alternative casualty units at King's, Lewisham and St. Thomas's.

The trust will continue to provide at Guy's a wide range of hospital services, many of them geared to the needs of local people. In fact, 80 per cent. of patients currently seen and treated at the hospital will continue to go there. In keeping with its pioneering traditions Guy's will be at the forefront of developing state-of-the-art diagnostic and day case and out-patient services. It will genuinely be a hospital of the future.

Mr. Simon Hughes

How can the Secretary of State accept the recommendation that a date be fixed for the closure of an A and E department when the number of people presenting to such departments is rising? How can she accept that recommendation when it is clear from the advice of the people who run that department that they need it for the foreseeable future and that it would be unsafe to predict when it will not be needed? The consultants say to a person that to remove an A and E department and leave a major hospital, which treats a huge number of out-patients, and which has in-patient beds, without an intensive care unit, will render it so dangerous that they will find it impossible to operate in those circumstances.

Mrs. Bottomley

The hon. Gentleman already knows that informing all our work on A and E services was the report by Sir Norman Browse and his team. We would not dream of accepting proposals if we were not satisfied that they conformed with the advice of the president of the Royal College of Surgeons and his team. The hon. Gentleman will also be aware that I have set not a date when the department will close, but one before which it will not close. I repeat my commitment that until or unless alternative arrangements are in place no final closure can take place.

I have sought not to speak at great length about the opportunities for medical schools and the link-up with the multi-faculty colleges at London university. The merger of Guy's and St. Thomas's offers a unique opportunity to develop the biomedical sciences campus on the Guy's site. It will become a major research and teaching campus as good as any in the country. I should also like to confirm again that Philip Harris house will be properly used—85 per cent. of the services it will provide will be those for which it was originally intended.

The future of Edgware hospital is of particular concern to some of my hon. Friends. A new £60 million hospital is being built at Barnet in north London, which brings to an end 25 years of uncertainty about the way forward for the two hospitals at Edgware and Barnet. Edgware hospital is not closing, because four out of five patients currently treated there will continue to attend.

As a result of the representations made by my hon. Friends, the opening of the proposed new minor accident treatment service will be brought forward to the earliest opportunity. They made a number of suggestions during the consultation period and subsequently, all of which I have sought to heed, take seriously and to match with practical proposals. Both the minor accident treatment service unit at Edgware and the new fully equipped and staffed casualty department at Barnet will be well established before full-scale A and E services move from Edgware.

The trust is already discussing with local GPs a possible GP presence at the minor accident treatment service unit. I have sought and received assurances from the local health authority and the London ambulance service that extra investment will strengthen the ambulance service in that area. The health service is investing in full non-emergency transport at Edgware to serve those who need to go to other hospitals. In addition, the Parliamentary Under-Secretary of State, my hon. Friend the Member for Bolton, West (Mr. Sackville), is having discussions with the Department of Transport about how we can improve transport arrangements further.

My hon. Friends the Members for Finchley (Mr. Booth) and for Hendon, South (Mr. Marshall) have argued strongly for the need to improve primary care in advance of the hospital changes. I am pleased to say that the regional health authority has decided to provide an additional £2 million—taking the total to £17 million—for improvements to family doctor and community services in the western part of Barnet, the area that is closest to Edgware hospital.

By 2000 we shall have spent more than £1 billion building a top-class health service in London. The programme of change has been preceded by an unprecedented amount of discussion, consultation and review. Decisions were needed to bring an end to uncertainty and delay for staff and patients alike.

Mr. Dykes

Will my right hon. Friend give way?

Mrs. Bottomley

I hope that my hon. Friend will bear with me, but I must bring my remarks to a close.

Now that the decisions have been made, it is vital that they are implemented sensitively, properly sequenced and carefully paced. For the period of transition, I give this seven-point pledge to the House. There will be no closures until alternative and better services are up and running. There will be modern emergency services, including an improved London ambulance service. We will continue to hold health authorities to account for providing comprehensive and effective services in each area, including a proper supply of beds to meet demand. Waiting times will improve further; the patients charter standards must be met.

Mr. Dykes

Will my right hon. Friend give way?

Mrs. Bottomley

I will not give way to my hon. Friend again, as I have already done so. We will continue to recruit and retain the very best doctors and nurses. The staff and the public will be involved in the changes so that they can see and contribute to the objectives. Finally, we will support innovation and development in teaching and research so that London maintains its prime position and we can invest in the next generation.

Since 1948, Parliament has given government the statutory duty to provide comprehensive health services for all who need them. We believe that we are building a health service in the capital that will serve our children and our grandchildren well, rather than the one that was right for our parents and grandparents—such is the phenomenal rate of medical advances. We have a crucial opportunity to prepare for the 21st century. The price of doing nothing—the price of Labour—would be to let our hospitals and our health service slip into decline and to fail London and Londoners. We are not prepared to pay that price.

We want a health service in which people can take pride. We shall succeed by holding firm and by being prepared to lead and not surrender. Edmund Burke said—[Interruption.]

Madam Deputy Speaker

Order. Hon. Members may not like what the Secretary of State is saying, but she is entitled to be heard, just as the right hon. Member for Derby, South (Mrs. Beckett) was entitled to be heard.

Mrs. Bottomley

Edmund Burke said: A state without the means of some change is without the means of its conservation". So it is with the health service. The Conservative party did not win four general elections by backing away from tough and sometimes, in the short term, unpopular decisions. We did it by sticking to our principles. Our duty is clear and our courage is intact. We shall hold firm because the interests of our health service, our capital and the rest of the country depend upon it.

Several hon. Members

rose—

Madam Deputy Speaker

Order. Before I call the next hon. Member to speak, I remind the House of Madam Speaker's decision that there will be a limit of 10 minutes on all Back-Bench speeches.

Mr. Harry Cohen (Leyton)

On a point of order, Madam Deputy Speaker. In her speech, the Secretary of State had an argument with my right hon. Friend the Member for Derby, South (Mrs. Beckett) about hospital closures. The Secretary of State said that she would clarify those figures later. Hon. Members who have tabled parliamentary questions about hospital closures, including me, have received the answer that the Department of Health does not keep that information centrally. Some of us would regard it as inconceivable— Madam Deputy Speaker: Order.

Mr. Cohen

It must have been lying— Madam Deputy Speaker: Order. I remind the hon. Member for Leyton (Mr. Cohen) that when the Speaker or the Deputy Speaker rises, the hon. Gentleman must resume his seat. It is perfectly clear that the hon. Gentleman is raising a matter of debate and of fact. The Chair is not responsible for the content of speeches.

Mr. Cohen

Further to that point of order, Madam Deputy Speaker. I am not raising a point of debate. I am asking you to investigate the answers to those parliamentary questions because I think that false information was given to hon. Members.

Madam Deputy Speaker

I thought that I made my point crystal clear: what is said in the House, whether it is correct or incorrect or falsely made, is not a matter for the Chair.

5.45 pm

Mr. Simon Hughes (Southwark and Bermondsey)

Today's debate is crucial for hon. Members who believe that the announcement that the Secretary of State made before the recess is misguided, wrong and not in the best interests of the health service.

I shall address my initial remarks to my colleagues in the House who do not represent London constituencies and who often attend debates on the London health service assuming that London Members are simply trying to persuade Ministers to give London more than it deserves. There is always a danger of a divide-and-rule approach to such debates.

I ask the Secretary of State: does she believe that the money that is currently allocated to the London health service is a fair amount, given the proportion of the population who live in London and who use its health service? It could have been argued some years ago that London received more than its fair share of resources. In general terms, 15 per cent. of the health service was located in London but it received 20 per cent. of the funding, but that is no longer so. There is no evidence to suggest that London receives more than its fair share of resources. Indeed, the rising population in inner and outer London is sufficient to suggest that the balance may need to be readjusted in the future.

No one is arguing against the rest of the country having a decent, renewed health service. Londoners argue that those who live in London and those who are sent here by their doctors or consultants for treatment—some of the centres of excellence in London health provision will continue in our lifetime to treat people from all over the country—should receive a fair share of resources, and that that share should be allocated fairly.

The motion tabled by the Labour party does not argue that all change within the London health service should stop. On that basis, the motion will be supported not only by Opposition Members but by some Conservative Members.

I understand that the Secretary of State receives particularly voluminous advice from many experts and advisers whom she has cited. However, she has not tempered that advice with experience on the ground.

The Secretary of State knows that I have gained practical experience, particularly from the three hospitals that serve the community that I represent—Guy's, King's College and St. Thomas's. The experience of patients and practitioners no longer accords with what the Secretary of State considers to be the unqualified and unalterable advice that she receives from her advisers within and outside the Department of Health.

As to acute services, practitioners are saying that the number of people who are presenting themselves for treatment in casualty and accident and emergency departments is rising, not falling. The number of people on waiting lists for out-patient appointments is rising, not falling. Figures show that people had to wait for 16 weeks in 1991 and for 40 weeks in 1995. The number of people in intensive care unit beds is rising, not falling. Many intensive care units are not just full but overspilling into other bed provision, which is not prepared for intensive care use.

The trend, and this is not invented by politicians or based on political rhetoric, is towards more pressure on the health service in the capital city. The worry, which is supported by evidence, is that when people need the health services of the capital they regularly cannot be admitted to them.

When a doctor rings up for a bed, no emergency bed is available. When patients arrive at a hospital, there is no space in the ward. London hospitals are meant to have enough capacity, but patients end up being sent to Leeds. The evidence is abundantly clear that, day by day, London health services are not working.

Mr. Duncan Smith

Will the hon. Gentleman give way?

Mr. Hughes

I will not because we each have only 10 minutes and I want to respect that limit.

One hospital after another has regularly had to close its doors because it just cannot cope any more.

Let the Secretary of State not meet one point with an answer to a different one. Nobody argues against new facilities or that we do not want old buildings such as Hunt's house in Guy's hospital knocked down. Nobody argues that we do not want Philip Harris house, which was built at a cost of £150 million, to be opened. We are arguing exactly the opposite.

We want the best facilities. That is why the argument for Philip Harris house is so clear: it is the best building in the health service. It would be madness not to use it for the purpose for which it was designed and built. However, we do not want commitments to changes in the future that the present circumstances do not appear to justify.

The right hon. Member for Derby, South (Mrs. Beckett) made a hugely important point about the waste of public resources. The health service is expensive, as it should be. It should provide the best possible care for everyone, no matter how poor they may be. It is nonsense to plan new buildings on one site when we have buildings waiting to be used on another. That is not a good use of public resources.

The argument that we are trying to win today, and for which we seek support from Conservative Members, some of whom have declared their support, is not about trying to unravel the health service reforms or changing direction. I am trying to win the argument, as was the right hon. Member for Derby, South, that the evidence does not support the academic and so-called expert advice that the speed, pace and details of the proposals are compatible with the needs of the different parts of the capital city.

Let me choose one example. The Secretary of State for Health wrote to me about Guy's last month and used an argument that I have often heard before as part of her case for closing Guy's accident and emergency department, although I think that she now accepts that it may be impossible to close it even in 1998 or 1999. If it is not possible to close it then, it seems foolhardy to set a date at all because it might take another five, 10 or 15 years or might never need to be closed. Why say that it will certainly be closed when it might not be?

In her letter, the Secretary of State says that evidence shows that between 25 and 40 per cent. of people who attend accident and emergency could be better treated by their GP. That is not uncontradicted advice. It is not even the balance of the advice.

There is strong research evidence that only 20 per cent. or fewer of accident and emergency patients could be treated by their GP better or more safely. In any event, the figure may be much nearer to 25 per cent. than 40 per cent.

It is the failure to accept that there is another side of the story that concerns me as a Member who represents 80,000 people in an area with some of the worst scores on the indices of deprivation, morbidity and mortality. It also concerns the people themselves who are saying, "For heaven's sake, don't ask us to write blank cheques." They do not trust that a better new service will replace the old one until the new service is there and working. When the ambulances turn up, when people are not kept lying in trolleys and when they are seen by nurses who do not leave people unattended because they are so over-stretched that they cannot cope, we will believe that London's hospitals are working.

Today we must ask the Secretary of State why she is unwilling on the basis of what she has said to concede that her proposals are causing concern and fear to users of the service and to accept the advice of practitioners, who are arguing the same case.

I have two other points. First, it is not sufficient to go through a consultation process and then ignore its results. It is no good having a semblance of consultation in the health service without taking account of the concerns of the people who have responded to that request for information.

It would be different if national health service trusts were democratically elected or local health authorities were democratically accountable because then, at the end of day, accountable people would be making the difficult choices, but they are not. The people on those bodies are appointed.

When bodies that meet in secret and are accountable to the Secretary of State, who by definition is a party political person, make such decisions, they do not receive the automatic confidence of the public and the public do not feel that they are being listened to by the people who make the decisions. I ask the Secretary of State to say that no proposal will be pushed forward unless and until it has the support of those who were consulted about whether it was right or wrong.

I shall use our local circumstances in south-east London as an example of my last point, but it applies to Edgware and east London as well. Many of the people who have advised the Secretary of State have made it clear to her that there are preconditions for what she says being acceptable. Our local health commission said that it needed £28 million extra to deliver changes that it was proposing. There has been no guarantee of that extra money, although a request has been made to the region. That is symptomatic of the way in which people are being asked to trust the administrators of a service which at the moment they see is not delivering.

At the end of Secretary of State's speech, she made her pledge, which had seven points. If I had to describe the end of her speech, I would call it a statement made by a Snow White of the health service with seven dwarf pledges following behind. Her pledge was mere words, and it is not borne out by the money that is available or by the evidence.

Nobody argues against renewing the health service. We argue rather that the health service in London should be developed with the consent of the people who use it. As with policing, one should not run a health service without the consent of the people. If the Secretary of State persists, I fear that she and her colleagues will pay the political price. I would rather that she retrenched and retracted now and listened to the overwhelming view of health service users who say that she is has got it wrong and should slow down, listen to the people and look at the facts. They can help her get the health service that Londoners need and deserve far better than her experts and advisers and the people who are not in the front line of the changes that she recommends.

5.58 pm

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

It is a pleasure to follow the hon. Member for Southwark and Bermondsey (Mr. Hughes). Before the great Reform Act 1832, when there were six Members of Parliament for what is now my constituency, there were two Members for the rest of Middlesex and two Members for Southwark. It is because we both have ancient seats that we have ancient hospitals and common cause in connection with them.

This debate has been years in gestation—not just the years since the Tomlinson report but the 80 years to which the Government's motion refers. I have spoken in three preliminary debates since Trafalgar day last year. I have expressed my general support for what my right hon. Friend the Secretary of State is seeking to achieve. There is no point in repeating the arguments that have already been rehearsed. I have stressed Bart's own recognition, as far back as 1977, that London specialties needed to be rationalised and concentrated.

A month ago, I criticised my right hon. Friend the Secretary of State for not coming to the House to make a statement. Although I do not think that the Executive should take the legislature for granted, I confess that I felt a little like Shakespeare's second murderer. I admire and respect my right hon. Friend, not least for her courage in tackling London's endemic problems, which have remained untackled for so long, and by so many of her predecessors. However, I have said time almost without number, and not least to my right hon. Friend, that merging an institution as great as Bart's is a highly delicate venture.

The three great opportunities for this country in the post-industrial society are government, education and medicine. Bart's features in two of those. Thus, the survival of its ethos and reputation in the merged institution is critical, as it is a national asset. For them to survive in an atmosphere of intense change requires a high sensitivity to people as well as to detail. On that score, the Government's ultimate handling of Bart's has been inadequate.

I am curtailed by the restraints of time, but I shall cite a series of instances, in no particular order. The background is that Bart's has been happy to engage in the merger but the issue is whether it should be on one site or on two. The failure of public education about Bart's future remains stunning. Long ago, I recall the noble Lord Flowers saying of the urban transportation of irradiated fuel that, although he might know it to be safe, what mattered was that the public should believe it to be so.

The public do not believe the Government's case about Bart's and the health authority's handling of the responses to the consultation will not have improved credibility. I acknowledge that there were several options in the consultation document. Because they did not respond to the document's precise terminology, those who asked for Bart's to remain open, which was implicitly a vote for the two-site option, were treated as having expressed no preference.

In the preparations for the new hospital, there are 32 clinical directorates. A total of 22—more than two thirds—are headed by staff from the Royal London hospital, and nine are headed by staff from Bart's. The Royal London is the host in the merger, and I can see no evidence of a change in welcome such as I said was needed as far back as the Trafalgar day debate last year.

Next I come to the press release of 8 March from the Royal Hospitals trust which is headlined: Royal Hospitals Trust hits back at defective report. I referred to that obliquely in the House on 5 April. The press release was an attack on the motivation of Bart's medical council and the professional reputation of the York Health Economics Consortium. It was issued five days before the health authority met to reach conclusions on the consultation.

Dr. Posnett, the director of the York Health Economics Consortium of the-University of York, did not go public with his reactions to the press release. On 17 March he wrote a reasoned letter of rebuttal to the chief executive of the trust. Nearly eight weeks later the chief executive has not replied. Dr. Posnett was specifically seeking to avoid a public row. However, to ignore a professional letter is not professional. Circulation of the correspondence to the trust board was first promised and then denied.

A single press release would not normally warrant such attention, but the conclusion of the York Health Economics Consortium had been that the business case for a £200 million investment on a single site at the Royal London had been insufficiently substantial to warrant not looking at alternative options more closely. In terms of the sensitivity of which I have spoken, the press release was crass and the silence since then has been contemptible.

On 21 October last year and on 5 April this year my right hon. Friend the Secretary of State and her hon. Friend the Minister of State said things about Bart's which history has since proved to be inaccurate. I do not quarrel with that because Ministers are only as good as the briefing that they receive. I hope that the briefing on the York report has been better, not least because of the circumstances.

Given the Secretary of State's concern to transfer the ethos of Bart's to Whitechapel and the health authority's confidence in the consultation document that this can be done, the financial aspects, although important, are academic by comparison with the practical consequences of this serial handling.

On 21 October I spoke of the need to ensure that the staff at Bart's should not haemorrhage away if the ethos was to survive. My right hon. Friend will know the figures. Against a background where, historically, few people have left Bart's—11 people have left, or will leave—the medical college since last August, two more are thought to be about to leave and seven others are at risk. Four of those earned absolute stars in the 1992 research ratings competition. A haemorrhage of that sort runs the risk of being fatal.

What should an individual Member do? I feel no sense of community with the chancers on the Opposition Front Bench. The predecessor of the right hon. Member for Derby, South (Mrs. Beckett) said that the status quo was no longer an option in London, yet the right hon. Lady comes to the debate without the courtesy of publishing her party's NHS policies in advance.

As the hon. Member for the City I also represent the western tip of east London. With the other hon. Members representing east London, for whom Bart's is a neighbourhood hospital, I do feel a sense of community. I am careful of the company I keep but hon. Members representing east London are entirely proper company at this time. My right hon. Friend the Secretary of State has said that she will pay attention to the view of the House and I must, on current knowledge, vote against her.

I realise that many of my hon. Friends will wish to give my right hon. Friend the benefit of the doubt. I would not ask them to come into the Opposition Lobby for they do not have the same knowledge of Bart's as I have. However, in a party such as ours, I ask them to pause for a moment to decide whether they should give Bart's the benefit of the doubt and abstain. I have seen the haemorrhage of staff already and I dread the haemorrhage that is to come. I cannot believe that any of my hon. Friends could read the York report, with its commentary on the methodology used to reach the single-site decision, without having a scintilla of doubt about what the trust, the authority and the Department are up to.

The financial figures are, in any case, finely balanced in a world where the Chelsea and Westminster figures could overrun as they did. If the House endorses the death warrant on Bart's, each and every one who votes for it is responsible. I respect the Secretary of State's certainty that she is right, for she knows how appallingly her reputation will be undermined if she turns out to be wrong.

My reading of the Government's capital investment manual reveals that it asks under the heading "Options": have there been any changes in available options and/or all these additional options that should now be considered? My reading of the York report reveals that consultation on alternative options should have occurred and should still occur.

On Bart's, I close with some words by Larkin, an unbeliever who said in church: It pleases me to stand in silence here; A serious house on serious earth it is, In whose blent air all our compulsions meet, Are recognised, and robed as destinies. And that much can never be obsolete, Since someone will forever be surprising A hunger in himself to be more serious, And gravitating with it to this ground, Which he once heard, was proper to grow wise in, If only that so many dead lie round.

6.8 pm

Mr. Brian Sedgemore (Hackney, South and Shoreditch)

It is an enormous privilege to have heard the speech made by the right hon. Member for City of London and Westminster, South (Mr. Brooke). We have always held him in high esteem and today, for the first time for a long time, we had a reaffirmation of honour in the House of Commons. We can only salute and applaud the right hon. Gentleman for the grace with which he delivered his speech and for the difficulty with which he has made his decision, for the moment, about his conflicting loyalties. We all know that loyalty to party often conflicts with loyalty to constituents, conscience and principles. The right hon. Gentleman has told us that, for the moment, he believes that it is right that he should go along with his loyalty to his constituents, his conscience and his principles. We salute him.

At the weekend, the Secretary of State called in some of the press and told them that she had a bundle of letters in support of her plans to close hospitals in London. I wonder how her bundle of letters compared in quantity to the 1 million people who signed a petition stating that Bart's should not be closed and to the 1 million people who signed a petition stating that Guy's should not be closed. I wonder how it compared in quality with the letters that Professor Lesley Rees, the dean of Bart's medical college, received from 344 heads of departments from 42 countries around the world and the 245 letters that he received from medical and scientific institutions from around the globe. I wonder how her little pile of letters compared with the shoal of letters—I have a copy of each one—that the Prime Minister received from top medical experts from around the world.

On the evidence of the correspondence that I have seen—I have looked through it all—the Secretary of State has been charged, indicted and found guilty by the public and by the medical establishment, not just in this country, but worldwide. It only remains for the House tonight to pass sentence and to seek retribution for what the Secretary of State has done.

Two weeks ago, the Prime Minister came to Hackney to praise Hackney council for its inner-city initiatives. He said that he wished there could be cross-party support for them and that Conservative boroughs as well as Labour boroughs could follow the example of Hackney. I was delighted to see him there and discussed some of the problems with him.

Hackney council said that it would work with anyone providing that it was in the interests of the council. It said that it would like some support from Conservative councillors on some of the steps that it wanted to take. Conservative councillors have voted for a motion that is an unequivocal indictment of the Secretary of State's proposal to close Bart's and the London chest hospital. They will be delighted with the decision of the right hon. Member for City of London and Westminster, South tonight. I think that they, like many other people, will be wondering anxiously about how other Conservative Members will respond to the debate.

Yesterday I visited Bart's to open an exhibition of paintings by patients in the Strauss ward—the only ward at Bart's that deals exclusively with those receiving treatment for mental illness. The exhibition took place in St. Bartholomew the Less, a beautiful church inside the hospital.

The irony is that the Strauss ward was opened on Wednesday 25 May 1992 by Her Majesty the Queen. Members of the royal family, including the Queen, have all been instructed that they are no longer to pay visits to Bart's, for fear that the anger that already exists due to the impending closure will be made worse. I asked yesterday and I ask the House today: what sort of a society is it where the Queen can be told by second-rate politicians that she cannot go in to the world's oldest and best hospital, even to open new wards or to see and respect some of its past glories?

Over lunch yesterday, I spoke to some of the consultants. I did not intend to stay for lunch, so none of the consultants were hand picked, and we had a general talk about what was going on. It was interesting that they all, without exception, said that they were angry and bemused. They said that, when challenged to produce a profit inside the internal market, they did precisely that. They said that, when asked to enter into a merger with the Royal London hospital, they did so in good faith and thought that it might work, only to be told shortly afterwards that it was not to be a merger, but the closure of St. Bartholomew's hospital. They accused the Secretary of State of bad faith and a lack of integrity.

The consultants used words similar to those that I heard the hon. Member for Hendon, North (Sir J. Gorst) use on television. They said that they thought that the Secretary of State did not listen and that some of her arguments were incomprehensible. Some of the consultants were ruder and said that they thought that the Secretary of State was unintelligent, was living in a fantasy world created by her civil servants and had lost all contact with reality.

I remember when the hon. Member for Hendon, North said movingly on television that there was an important thing called a political process, in which one had to take note of people's fears, people's aspirations and—a phrase that I particularly remember—even people's prejudices. I do not believe that the 2 million people who have signed the petition are all prejudiced, but even if they were, it would be extraordinary for a Secretary of State to say, "You 2 million people have had your say, now listen to the experts. I am going to get on with it and take the advice of my civil servants." That does not seem to be the way to conduct politics seriously.

The right hon. Member for City of London and Westminster, South spoke about the haemorrhaging of the centre of excellence at St. Bartholomew's hospital and of the staff that were leaving. The dean of the medical college yesterday faxed me some updated figures. I am afraid that they are even slightly worse than the right hon. Gentleman said. I have the fax and the names—obviously, I will not read out the names.

The figures show that seven professors and six senior lecturers have already been lost and are going to such places as Sheffield, Manchester, Oxford, University college hospital and the Royal Free hospital. They also show that four professors, three senior lecturers and a recorder are at risk.

Some people may say that the figures amount to only 20 people and there are hundreds of people carrying out research at Bart's, but it is important to remember that each senior figure who goes will take a clutch of research workers with him or her. Those research workers do not just carry out abstract medical research; they help with the provision of clinical services at Bart's. They have been helping, not only at Bart's, but at the Homerton and the Queen Elizabeth hospital for children in Hackney.

One does not need to be super intelligent to realise that the Homerton could seriously suffer in the future because it is no longer linked to a teaching hospital. It does not have the links that it should have with the Royal London hospital and St. Bartholomew's hospital. We need to consider medicine in east London in the context of the Royal London hospital, St. Bartholomew's hospital, the Homerton hospital and, probably, hospitals in Newham, and come up with a sensible solution and sensible amalgamations. There is no need for war between St. Bartholomew's hospital and the Royal London hospital.

A few weeks ago the Secretary of State said that the ethos of Bart's could be transferred to the Royal London. From a sedentary position my hon. Friend the Member for Bolsover (Mr. Skinner), who was here at the time, asked how the bloody hell we could transfer an ethos. I phoned up the Department of Health and was told that it could be bottled and transported. I was told that the extract of Bart's would be issued in bottles to each of the patients moved to the Royal London hospital.

Mr. Deputy Speaker (Mr. Michael Morris)

Order. I call Sir Nicholas Scott.

6.18 pm

Sir Nicholas Scott (Chelsea)

Hanging in my office in the Norman Shaw North building is a cartoon that was given to me in 1987. It was drawn by that marvellous cartoonist, Marc. It shows two Back Benchers—I think that my hon. Friends would probably recognise them—and one is saying to the other: I used to have this nightmare that she'd made me Minister for Northern Ireland, but lately it's been Minister of Health". I do not think that many of us in the House envy my right hon. Friend the Secretary of State and her team of Ministers some of the difficult decisions that they are having to face as they try to ensure that constituency Members of Parliament and existing institutions are properly looked after while at the same time ensuring that we have a health service for London that is up to date as new developments and new techniques are introduced into the health care of our capital city. They have a difficult job, but we too have a difficult job. I ask my right hon. and hon. Friends to understand how difficult that job sometimes is when, as my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke) said, marvellous institutions with long histories are too easily challenged and face extinction.

We look at the arguments and the statistics in the Tomlinson report. We refer to a report by Professor Jarman, which challenges many of those ideas and statistics. We listen to my right hon. Friend the Secretary of State and to my hon. Friend the Minister on the "Today" programme, with a soothing and, I am sure, accurate flow of statistics to challenge some of the arguments that are being put against them. We then look at the Evening Standard and the claims of the community health councils. It is difficult for us, as constituency Members of Parliament, to see where the real value in the arguments lies.

I know that my right hon. Friend wants to get it right not just for today's London but for tomorrow's London, and that gives her several difficult considerations.

Sometimes, too little notice is taken of a number of factors other than the existing population and the existing needs of the population of central London. The population of central London does not consist entirely of those who have a residence in central London. We have a huge additional daytime population whose needs must be met by many hospitals in the city centre. We also have a considerable number of overseas residents, visitors and tourists who might need attention by our health service. Many visitors come to this country specifically to take advantage of the excellent health service in central London, and they bring with them other economic advantages to the centre of London.

There are two other factors that we should bear in mind when we look at the pattern of health provision in central London. I understand the first factor, because the Department in which I recently served shared some of the burden of it with the Department of Health. I refer to the policy of care in the community—perfectly proper and perfectly understandable. There is no doubt at all in my mind that a significant number of those who have been released from institutional care and put into community care packages need from time to time to go into mainstream hospitals in central London because of a deterioration in their condition. Perhaps there is no other place to which they can turn to be properly looked after.

We should not ignore the possibility of terrorism as we look at the need for hospitals in central London. I am not talking about Northern Ireland and its influence on this side of the water, which we have had to endure for many years. However, bearing in mind what happened in Oklahoma and the growing number of organisations that seem to believe that they can turn to terrorism to publicise and achieve their ends, we must take account of that trend as we consider proper health care provision in our major cities, particularly in London.

The second factor that all Members of Parliament in central London can regard with pride, and for which we must fight to ensure its continuity, is that London maintains its widely recognised reputation throughout the world as a centre for health excellence. We must not lose that. I know that my right hon. Friend wants to keep that reputation and, indeed, to enhance it, and it should be a major factor in our consideration. We should consider not only the existing population who need such services in central London, but those from across the world who come to take advantage of them.

I have three major hospitals in my constituency. One is the Chelsea and Westminster hospital—a new, flourishing, expensive hospital. Whether in today's terms that hospital would ever have been built is not for me to say, but it exists and it is performing extremely well. It is still not used to absolute capacity. It has an excellent contract with the Kensington, Chelsea and Westminster health agency. I believe that it has a glittering future.

Since that hospital opened in early 1993, the number of in-patients and day-patients has steadily increased by more than 15 per cent. in each of the two years that the hospital has been open. Attendances at the accident and emergency department have increased from fewer than 40,000 in the first year to more than 60,000 this year. I recently paid a visit to that A and E unit, and I speak very strongly in support of the service that it provides.

That hospital has also introduced something that exists elsewhere—I hope that the practice will steadily increase—and that is a rota of general practitioners serving in the A and E department in the evenings. They are able to cope with the less serious visitors to the department, just as GPs would in their own surgeries. We should encourage that development in our hospitals.

The Royal Marsden hospital is also in my constituency. On 21 April, my hon. Friend the Minister was asked whether he had had any meetings about the closure of the Royal Marsden hospital and whether he had any plans for its closure and he answered none to both questions. I hope that I can count on him to continue to use that precise and brief answer to subsequent questions. There is no doubt that the Royal Marsden is a fine institution with a glittering reputation for high-quality research, and it deserves to flourish in future.

The third major hospital in my constituency is the Royal Brompton. My hon. Friend the Minister knows that board members of the Royal Brompton hospital have invited companies to meet them with a proposition to introduce a new ambulatory care centre without beds, to be known as the Royal Brompton clinic, which might be developed using the private finance initiative that the Government recently introduced. The private sector has shown great interest in that proposition. We have the chance, in Sydney street in my constituency, to have a new day clinic for respiratory and heart cases, along the lines of the Mayo clinic in the United States of America, and not costing a penny to the Exchequer but provided by private finance. It would be a tremendous addition to the quality of health care in central London.

I very much hope that my right hon. Friend the Secretary of State -and her team of Ministers will be able to overcome any objections that may be encountered elsewhere in the Government in order to bring that imaginative scheme to a proper conclusion.

My right hon. Friend has shown great political courage in the way in which she has tackled her job. She needs, too, clear judgment about the future needs of London against the background that I have sought to describe in this brief speech. In the months and years ahead, that will be a difficult task for her, but I wish her well.

6.27 pm

Mr. Jim Dowd (Lewisham, West)

The right hon. Members for City of London and Westminster, South (Mr. Brooke) and for Chelsea (Sir N. Scott) have injected the reasonable and measured tone that such debates sometimes lack. It is a shame that, on occasions, our debates are reduced almost to cliché and stereotyping. The idea that this debate is an argument about London versus the rest of the country is not only inaccurate but fraudulent, and those who peddle it do so to try to obscure what is happening in London.

As my right hon. Friend the Member for Derby, South (Mrs. Beckett) said, the debate is of much greater significance; it is about the shape, nature and purpose of the national health service after the market reforms. What is happening in London hospitals today is only because they have been at the sharp end of those reforms, and it will ripple into other parts of the country before long.

The allocation of resources to health will always be difficult for any Government. I speak as somebody who was a member of the area health authority for Lambeth, Lewisham and Southwark from 1976, and who became a member of the district health authority for Lewisham and north Southwark, which succeeded it.

I and my colleagues on that authority spent many of those 16 years ensuring that we got the best value for money. Many of our decisions were extremely difficult. Sometimes we were comparing apples with oranges, but decisions had to be taken in the best interests of the people in the area.

In one of today's newspapers, the Secretary of State apparently attacks me for not supporting the Government's investment in the improvements to Lewisham hospital, among others. That was another piece of shorthand. Over the years, I was deeply involved in what became phase 2 at Lewisham and phase 3 at Guy's.

Philip Harris house has already been mentioned this evening. I am pleased with what has been achieved. My major concern, and the reason why I am speaking this evening, is that so much of that achievement is being put at risk. The improvements at Lewisham are welcome, but they have not achieved the objective of providing a service adequate to the needs of the area.

When the proposals for the future of Guy's and St. Thomas's were put out for consultation by the current health authority, the majority of responses outside the area immediately surrounding Guy's hospital were from people in my constituency who overwhelmingly used Lewisham and King's. That is because those people know that Lewisham and King's cannot cope at the moment, let alone if the accident and emergency department at Guy's were to the close.

In 1976, when I started on the health authority, there were about 16 hospitals in Lambeth, Lewisham and Southwark. Today there are four. Anybody who says the idea of change is new and needs to be faced now is misleading himself. Change in the provision of health care in London has been a fact of life, certainly since the formation of the national health service.

Many of those hospital closures were bitterly contested at the time. The decision to close Sydenham children's hospital had the capacity to be extremely emotional. I supported the closure of that hospital for a number of reasons, not least of which was how the process was approached. Ultimately, the authority and the clinicians convinced people in the area that a better service could be provided elsewhere—at Lewisham hospital. It was only with some reluctance that the people in the area agreed to the closure of Sydenham children's hospital, and subsequently moved to Lewisham hospital, which is doing very well.

That element of consent is totally lacking in the issues before us this evening. What has been most clear in the process post-Tomlinson is that change has been pushed forward almost with a life of its own. Theoretically, the people of London were consulted, in so far as they were given the opportunity to write letters to the Secretary of State and their local health authorities, but there is a widespread feeling that the consultation was a sham, and that nothing they said, except at the very periphery, was taken into account, and their views had no impact on the decisions that were taken. The issues that we are discussing this evening involve public confidence as well as health care provision.

The timetable for Tomlinson was set four or five years ago. A great deal of contrary authoritative information has emerged as the process has unfolded, and there is some doubt as to whether Tomlinson has achieved its objective. For example, since 1992, bed closures across the country have reached some 3,000, and 45 per cent. or more than 1,300 were in London alone. That shows how rapidly health care provision—certainly acute provision—has changed in London. Mention has been made of the Jarman report, the work of the King's Fund and others.

It is not reasonable, particularly in the case of Guy's, though the same case can be made for other hospitals, that no alternatives have been produced. The "Save Guy's Campaign"—I pay tribute to the hon. Members for Southwark and Bermondsey (Mr. Hughes) and for Chislehurst (Mr. Sims), and to my hon. Friend the Member for Dulwich (Ms Jowell), who have done so much work for that campaign—got KPMG Peat Marwick to carry out an extensive and detailed analysis of the options available under two or three site configurations, in concert with Guy's, St. Thomas's, University and King's College hospitals. Nobody said that it was the perfect blueprint, but those proposals made it clear that there was room for a reasoned and informed debate to decide on an alternative to the current proposals.

Hon. Members on both sides of the House are concerned about the proposals for accident and emergency provision at various hospitals, because the accident and emergency department is the heart of a hospital. All experience shows that, once the casualty department is closed, before the- decline of the rest of the hospital is simply a matter of time. It is sometimes accelerated and sometimes delayed, but it is inevitable. That is why the accident and emergency unit at Guy's is critical for people in south-east London who have been at the forefront of change in acute provision in London.

A perfectly reasonable argument has unfolded over the years for the rationalisation of specialties. The arguments are far more technical, although the assessment of their benefit is easier to calculate than that for accident and emergency provision. The rationalisation of specialties will always cause dispute, but there is more broad agreement, certainly in the light of technical and technological developments, about how developments should unfold. Accident and emergency provision is an entirely different matter, as that is how people define their local hospitals.

The hospitals in south-east London, including Guy's, cannot cope with the current demand. Speaking to a friend, I asked after his mother, who is one of my constituents in Sydenham. He informed me that she had been very ill with pneumonia, and that at one stage her GP wanted to admit her to Lewisham hospital. He said that had there been a bed available, she would have been admitted.

When I asked him what he meant by that, he said that, when they had asked for a bed at Lewisham, Hither Green or Guy's, no beds were available, so she stayed at home. Fortunately, she is better now, but those decisions cause not only distress to the individuals concerned but untold distress, inconvenience and worry to their families when they are given medical advice that they should be admitted to hospital but they cannot get in.

I was interested to hear the Secretary of State further refine the delay in announcing the closure of Guy's. She has now given a date before which it will not be closed. That is another tactical retreat, which will enable her to come back and steal the show by announcing a date 20 years on from that, and by then we might have dealt with many of the issues relating to Guy's. The announcement of the delay in itself shows how overwhelming pressure has been against the proposals of the trust.

The trusts are unresponsive, and the performance of the London ambulance service remains a source of considerable concern to all of us in London. Sadly, the figures are deteriorating, after a marginal improvement.

The Secretary of State's decisions are virtually irreversible, but the motion provides an opportunity to think against before it is too late for the people of London and the NHS they prize.

6.37 pm

Mr. David Mellor (Putney)

It is a pleasure to follow the speech of the hon. Member for Lewisham (Mr. Dowd), who was extensively involved in the health service. I agree with a number of the points he made about health services in London that were refreshingly free of the partisan camp that so often disfigures such occasions. There has been a measured quality to the debate that might not have been anticipated, given some of its pre-publicity.

One of the reasons that impelled me to speak was my anger at the campaign of vilification that has been mounted against my right hon. Friend the Secretary of State in recent weeks. It is inevitable in the extremely difficult waters in which she has to fish.

As one of those who took on the job of Minister of Health not long after the cartoon to which my right hon. Friend the Member for Chelsea (Sir N. Scott) referred, I can assure him that, of all the posts I occupied in 11 years in government, health was far and away the most stressful and difficult. The Archangel Gabriel himself would have difficulty emerging in pristine condition from occupying that post.

It was a genuine pleasure to be in the House to hear the exceptionally eloquent and stylish speech of my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke). The fact that he takes the view that he does is a sign of how difficult is the task of my right hon. Friend the Secretary of State.

All of us who care about the health service in London will be concerned about some things that are happening, and all have reservations about some of the detail of the proposals. However, overall there is no doubt that that which my right hon. Friend is doing needs in some part—probably the greater part—to be done.

It cannot be ignored or avoided by anybody who wants to discharge effectively the office of Secretary of State for Health with any distinction, particularly in the eye of history. I hope that it will be possible to conduct debates without trying personally to vilify the holder of an office merely because that individual cannot shrink from taking difficult decisions.

I need not rehearse the justifications for Government policies. London is no longer the place to which patients from all over the country must come for a range of specialist treatment. It should be a matter of pride that, under this Government, we have for the first time a truly national health service. One can have a heart transplant at the Freeman hospital in Newcastle, and St. James's hospital in Leeds is a European leader in liver surgery. Nobody is far from a modern hospital that can fulfil almost all their needs.

Whether we like it or not, the transformation of some central London hospitals from great centres of excellence offering services to a substantial part of the nation to district general hospitals was always going to be difficult and painful. That does not mean that some of the decisions and detail should not be examined, and I cannot quarrel with a number of the points made on behalf of Guy's and Bart's. It is clear that London could not go on the way it was.

The right hon. Member for Derby, South (Mrs. Beckett) has left the Chamber. It would have helped if at some point in her speech she had recognised that the process of reducing the number of hospital beds in London began under the last Labour Government, which established the London Health Planning Consortium—although it reported in the first 12 months of this Government.

My hon. Friend the Member for Reading, East (Sir G. Vaughan), who was Minister of State for Health at the time, will remember that the consortium recommended 6,200 bed reductions overall, amounting to 20 to 25 per cent. of central London's bed stock. If, by some miracle, Labour had won the 1979 general election, presumably it would have embarked on much the same course, because it set in hand the first substantive report.

I longed—in the course of a speech that lasted half an hour and seemed much longer—for the right hon. Member for Derby, South to say what Labour, which we are now meant to see as a credible and serious party of government, would do to deal with London's health service. It is deplorable that we were treated to an opportunistic assault on the Government, merely for being the people who must run the health service.

If one day—contrary to our wishes and expectations—the right hon. Member for Derby, South became Secretary of State for Health, the idea that people would be cheering her through the streets six months after she had taken office is ludicrous—the right hon. Lady, in her innermost thoughts, must realise how deeply ludicrous.

It is also ludicrous for the Labour party to imagine for one moment that it can get away, in the run-up to a general election, with making low-road points about the Government. The Opposition must say what they intend. They made that mistake before. They are unaccustomed to answering substantive points, and fall apart in the run-up to an election. In their private thoughts—although they would not admit this—they must be only too aware that that is the likely fate that could still overtake them, however full of optimism they are at the moment.

I will turn to one or two points of substance. I made it clear that I accept that my right hon. Friend the Secretary of State must take the steps she has, but it is inevitable that there will be resentment on these Benches and everywhere else if it appears that the health service that was subject to the major reforms introduced by my right hon. and learned Friend the Member for Rushcliffe (Mr. Clarke) are still being run according to the principles of a group of faceless people at different tiers, making decisions of fundamental importance as to which institutions remain open and which do not.

I was there at the formation of the policy, and it was always my understanding that the aim of the reforms was to empower patients and their doctors, and that the new mechanisms were to be responsive to their choices. The whole purpose of self-governing hospital trusts was to allow hospitals to respond in a much freer way to patients than before and to offer services whose popularity or otherwise would make it possible, with cash following the patient, for institutions to succeed or fail.

A number of us find it difficult that a number of manifestly successful institutions can nevertheless be challenged by what appears to be a return to the old-style dirigiste principles that I hoped had gone out of the window with the advent of the reforms. I say that in relation to Queen Mary's University hospital, Roehampton. I am grateful to my right hon. Friend and to the predecessor to my hon. Friend the Member for Winchester (Mr. Malone) for determining last year that the threat to which Queen Mary's was subject should be lifted.

Mr. Sedgemore

Now we understand.

Mr. Mellor

I shall fight for the hospital in my constituency, as the hon. Gentleman fights for his. If I do so more successfully than the hon. Gentleman, he can draw his own conclusions.

Of the four hospitals in south-west London that were under scrutiny, Queen Mary's University was the hospital that doctors and patients regarded most highly. That was a reason for promoting its cause, and that cause was successful.

The problem for the health service is that there are too many cooks stirring this particular broth. I particularly draw to the attention of my hon. Friend the Minister the role of purchasing authorities. At present, Queen Mary's hopes to pioneer a new way of making hospitals more responsive to community needs through the rapid diagnostic centre, for which the region has already made £2 million funding available for the coming year. However, Kingston and Richmond health authority is now intervening and holding a pistol at the head of Queen Mary's, saying that, unless it is prepared to announce plans for closer co-operation with Kingston hospital, the investment cannot proceed.

It is the role of purchasing authorities not to usurp such functions, but to facilitate the choices that doctors and their patients make. If I walked down Putney high street today, none of my constituents would be able to identify one member of those health authorities. The Government would get the blame if things went wrong.

As my right hon. Friend and her colleagues have found, trip wires are set for them by people who are grinding their own axes and who hold no responsibility for maintaining public confidence in the health service or for ensuring that a manageable pace of change is promoted. Against that background, it is extremely important that processes go forward with a recognition that there are political elements in this that are too important to be left to the experts.

6.48 pm

Mr. John Austin-Walker (Woolwich)

It is timely to remind the Minister of the comments of the hon. Member for Hendon, North (Sir J. Gorst) on 5 April, when he asked the Secretary of State: Does my right hon. Friend accept that democratic politics is about delivering to people what the majority want, and not about telling the majority of people what they should have? He said: she is doing the wrong thing, in the wrong way, at the wrong time and in the wrong place."—[Official Report, 5 April 1995; Vol. 257, c. 1738.] The hon. Gentleman was referring to the problems relating to Edgware general hospital, but the same applies to other Greater London hospitals, such as Oldchurch and Greenwich district.

When I visited Edgware, I was struck by the lobby outside. Those people were not the usual rent-a-crowd lobby that one might have expected outside a hospital proposed for closure. I was handed a leaflet by a constituent of the right hon. Member for Brent, North (Sir R. Boyson), who I believe was also a member of his party, relating to Edgware. It said: Five CHCs agree with the people, all the local MPs agree with the people, the GPs agree with the people. Those who want to close Edgware have no friends. The Secretary of State and the Minister for Health seem incapable of listening to any advice from any source with any contact with the service that is being delivered.

One comment that has been made to me in relation to Edgware, which has also been made in relation to the Brook, Greenwich district and the move of Oldchurch to Harold Wood, concerns the beds that will be lost in the process. I am continually told by the Secretary of State and the Minister that the new proposals take into account the changes in practice, developments and techniques, the increase in day surgery and the shorter stay in hospital, and that that is why there may be a bed loss.

That might have some credence if there were spare beds at the moment. But in all those hospitals, not only are there no spare beds, but bed occupancy is higher than the Minister recommends as a reasonable level and it is achieved by the use of trolleys and beds in corridors.

Hon. Members who have been patients awaiting an operation will appreciate that, no matter how routine an operation is for the hospital, for the patient it is a traumatic experience. To have to psych oneself up and prepare for the trauma of an operation only to be told on the day of or the day before the operation that no bed is available is not the kind of hospital service that people in London deserve or expect.

The Secretary of State referred in her opening remarks to the Brook hospital and neurosurgery. She says that she wants to locate neurosurgery services close to an institute of academic excellence, close to the Institute of Psychiatry at the Maudsley. Why does she not talk to the neurosurgeons at the Brook hospital and throughout London who question the rationale of locating neurosurgery with a psychiatric unit?

No one denies that some patients who need neurosurgery may at some stage require some psychiatric services. But neurosurgery should be accessible to patients and located close to a major trauma centre. The hon. Member for Gravesham (Mr. Arnold) spoke about taking services out of central London to the areas that they serve. I remind the Minister that the Brook neurosurgery service and the Brook cardiothoracic service serve the people of south-east London and north-west Kent. To move those services to Guy's, St. Thomas's and King's, further into central London, makes no sense at all to the people of Gravesham, Chislehurst or Old Bexley and Sidcup.

It is not just Labour Members who have made such representations. The right hon. Member for Old Bexley and Sidcup (Sir E. Heath), the Father of the House, has called for a meeting with the Secretary of State to discuss the Brook neurosurgery services. Those services should move with the rest of the Brook hospital services into the new Queen Elizabeth military hospital. But if they were to go to Queen Mary's, Sidcup, I would not complain, because at least they would be located in a key area serving the sub-region.

Dermatology services do not receive a great deal of publicity, and people do not think that they are particularly important, but they are one of the most heavily used medical specialties. We have talked about the loss of beds. London has seen 70 per cent. of dermatology beds disappear. The dermatologists do not argue that all those beds need to be maintained. They accept that there can be some rationalisation of beds and their location in centres of excellence. But with the disappearance of those beds has gone 60 per cent. of the dedicated dermatology nurses who would be required to provide the services in out-patient clinics and in the community. Why were the dermatology services not the subject of a specialty review and why was there no input from the London dermatology planning group in any of the Minister's considerations? Those matters need to be considered.

The Minister will know that the Select Committee has considered the London ambulance service. I do not want to speak at great length about that, but I say simply that it is on the record that almost every person who gave evidence to the Select Committee said that the drastic reduction in accident and emergency units in London had been a contributory factor to the problems of the London ambulance service.

People talk about the response times of the London ambulance service improving, for which, at the end of the day, the Minister is responsible, but in the key area of the rapid response time there has been virtually no improvement during the past two years since the Minister has taken up the matter.

The right hon. Member for Chelsea (Sir N. Scott) referred to psychiatric services. I agree with all the points that he made. We have heard about over-occupancy of beds in London. Nowhere is that more apparent than in the area of psychiatry. My local hospital is talking about bed occupancy rates of 120 per cent. We have heard of patients from Sidcup having to be flown to Leeds for acute services. In psychiatry, it is not uncommon for patients from Greenwich and Woolwich to have to go as far afield as Oxford or Woking on a regular basis. A consultant psychiatrist has said that it is not uncommon for patients to have to wait some 36 hours to be placed and for telephone calls to have to be made to up to 35 different hospitals. That does not imply a pattern of over-provision in London.

I want finally to say a word about the Tomlinson-Jarman debate. Tomlinson was considering acute services in inner London, not the totality of health services across London. I do not think that anyone, certainly not Professor Tomlinson, would dispute the figures that have now been put forward on the totality of care in London by Professor Jarman. In the conclusion of his article in the British Medical Journal, Professor Jarman says: It is clear that neither hospital use by London residents, nor the availability of hospital beds, nor considerations of relative efficiency provide a case for a reduction of the total bed capacity in London … It is important that any changes should be considered in the context of London's transport system and the particular problems in primary care and social services, relatively longer hospital waiting lists, below average availability of places in residential homes, and the increasing pressure on available hospital beds. That is why so many Conservative Members are so concerned. We all accept that there is a need for change in London, but the pace of change and the kind of change that is being proposed are wrong.

With regard to the Government's assumption about the improper use of resources, we all accept that primary care in London is underdeveloped, but the secondary care should not be taken away before the improvements in primary care are put in place.

6.57 pm

Sir Rhodes Boyson (Brent, North)

The proposals for Edgware hospital have probably given rise to the greatest cause for concern in my constituency in the 21 years that I have represented it. People in London have a certain expectation of their hospitals. They are used to having specialist hospitals—such as Bart's and Guy's—in the centre, with a spread of friendly little hospitals around. That is why they feel so strongly about Edgware hospital.

We all accept that there must be reorganisation. We all accept that experts must be consulted. But I do not believe in the rule of experts. Experts can change their minds. It was the experts who ruined education in Britain with the discovery method and comprehensivisation, from the shackles of which the Labour party is now freeing itself.

What worries me about my right hon. Friend the Secretary of State, for whom I have obvious respect, is that she spends so much time talking about the experts rather than the people at the bottom of the pile who know what it is like in their area. The same applies to the size of schools and hospitals. Schools have now returned to their previous sizes. I have always said that in 10 years' time the present fashion will change, and change will be necessary.

Consultation has been mentioned. There has been no real consultation with the man and woman in the street, although various semi-quango committees have given their opinions. Perhaps ordinary people should have written letters, gathered in the streets or marched. In any event, the lack of consultation with them has made the position more difficult.

I have been re-reading some of what has been said about elective dictatorship. A Parliament is elected for five years; a large number of us are members of the Government, and a certain number are parliamentary private secretaries. They are all very good people; I am surrounded by them, so I am living dangerously. The Executive, however, has taken over Parliament, and it has become more difficult to ask whether the system is working and whether it is possible to do things in a certain way.

Between 1986 and 1990, Edgware's accident and emergency department was rebuilt; three years later, its future was threatened and it began to be run down. It seems that, if we live long enough, we are bound to be in fashion at some point.

Leadership means convincing our constituents that we are acting in accordance with their best interests. I accept that that is difficult when it comes to the health service. Last week, the mayors of our three boroughs came to the House. They were seen not by the Secretary of State or the Minister of State, but by the Under-Secretary of State, my hon. Friend the Member for Bolton, West (Mr. Sackville). Bolton must be a good place; certainly the football has not been too bad this year. What the mayors reported to the council, however, did not make the council feel very confident that its views had been properly represented. Some higher contact would have been useful.

Another problem is travel. It takes 45 minutes to travel from Edgware to Northwick Park on the 83 bus, and it costs 80p; it costs about £1.20 to travel to Barnet, and the journey can take up to an hour and a quarter. By that time, a person could be dead. As for ambulances, we do not know when they will arrive—and how fast they can move through the street: in many instances, they can move no faster than a bus. If an ambulance is stuck behind a bus for 10 minutes, there may be another two fatalities in that time.

A letter that I received this week from a rabbi in my constituency shows the level of concern. He wrote that the closure of Edgware general hospital would not only put at risk the lives of my own members, but also of all the residents of Brent … I therefore earnestly request that you make known our concerns at the highest levels. It seems totally criminal that the Government is determined to effect their policies, without any regard for the welfare of the population. That is the feeling not just of the rabbi and his congregation, but of many people in the area. If we are to get things right, a good deal of public relations and change will be necessary in Edgware and elsewhere. I hope that the Department will see to that in the morning, and will consider what we can do in Edgware to set people's minds at rest.

In the current circumstances, I cannot support the Government tonight. It gives me no pleasure to say that, but we are debating a major issue, and I speak on behalf of my constituents. I hope that there will be further discussions in the long term, which will reassure both them and me.

7.4 pm

Mr. Nigel Spearing (Newham, South)

I have probably discussed the Black Paper of the right hon. Member for Brent, North (Sir R. Boyson) with him for as long as 30 years. I believe that he would be a much better author of a White Paper on health than the Secretary of State.

I wish, however, to return to the point made by the right hon. Member for City of London and Westminster, South (Mr. Brooke). Exactly six weeks ago, he, my right hon. Friend the Member for Bethnal Green and Stepney (Mr. Shore) and I attended on the Secretary of State to beg for a different decision on east London. I think that the right hon. Gentleman struck the right note: in this debate, constituency interest has properly overridden older and, perhaps, more permanent loyalties.

I believe that the health service reflects—in the minds and hearts of the people of this country—the common faith shared by some hon. Members: the same faith that motivated St. Bartholomew. Some of us could deliver sermons about what has happened to saints in the past—and, indeed, to the originator of our faith. We might draw parallels with what is happening to St Bartholomew's hospital.

I do not think that the Secretary of State understands what she is about. I try not to say anything about people that I am not willing to say to their faces. Some time ago, when the right hon. Lady was struggling to give answers to questions on a statement, a benign Opposition voice shouted, "Come on Virginia, you can do better than that." "Oh no, she can't," someone said. I am afraid that that is true of the right hon. Lady's performance.

The Government amendment refers to benefits to be gained from "new and better services". That may apply to some services, but far more are worsening and diminishing. Newham general hospital has only seven posts of an establishment of 11 in its accident and emergency department. In the past few weeks I have learnt that it is not a requirement of the Royal College of Surgeons for qualified surgeons seeking membership to serve in such departments. I learned that from a parliamentary answer given by the Minister of State. What on earth has the Secretary of State done about it? Surely the Royal College of Surgeons recognises that such service is a national duty—but, if it does not, the right hon. Lady should have advertised the fact, and perhaps changed the policy of the college.

The Secretary of State's plans consist entirely of projections—the projections of Tomlinson, the King's fund and so forth. We have heard a great deal about her projections in regard to the ambulance service. I have said time and again that they were inadequate and that the Secretary of State had got it wrong; I have been told, "Oh no, it is all right. We have the funds." After five or six years, an extra £14 million had to be injected into a service that is nowhere near as complicated as the health service as a whole. If the right hon. Lady and her colleagues have got it wrong in regard to the ambulance service—and they have, to the tune of £14 million—how can we expect them to get it right in regard to beds in London? I do not believe that we can.

On 26 April, I secured a half-hour debate in which I made various accusations about what was going on. The Minister was good enough to write to me and did not deny some of the points that I made. I mentioned Homerton hospital. Despite the warnings, the right hon. Lady has lauded it to the skies when clearly it is not adequate for the task.

In her speech, the right hon. Lady mentioned the London chest hospital. I agree with her. Why should people come from Plymouth to be treated at the London chest hospital, which deals with respiratory diseases—a problem that is on the upturn in London, particularly among children? They should not have to do so, but people from Petticoat lane will not be treated there, because the hospital is being closed. The Minister cannot deny that fact.

Nor can the Minister deny the fact that a teenager desperately in need of psychiatric assistance had to be put in a police cell in Newham because secure accommodation was not available, and that 250,000 people in the borough of Newham had one psychiatrist in post a week or so ago. For all I know, that position continues today. The right hon. Lady, those who advise her and those who support her have no grip of what is really going on.

I refer now to the speech of the right hon. and learned Member for Putney (Mr. Mellor). A deeper malaise has yet to be identified. Surely within the organisation of the health service, a number of vicious, declining spirals exist. Units, trusts, authorities—all of them have had their marching orders. Because of that, they are unable to co-ordinate together.

Health provision is not a business. Sainsbury's and Boots provide only what they wish to provide, unless they prescribe medicine. They take goods, cut them up, put them on the shelf, freeze, process and transport them. There is a willing buyer and a willing seller—that is the market. But each of us is unique in our health requirements. Health provision is a service, not a business, and in their White Paper entitled "Working for Patients" the Government have tried to turn what was essentially a service into a business.

Last Monday, I could not rejoice. The post-war period was one of consensus. I know that party differences existed, but for nearly 40 years from about 1950 to about 1990 a consensus existed among the people of this country and in the House about the national health service. I hope that we get it back because it has been shattered, as have other services. The health service especially affects the needs of the elderly and of women.

I could not rejoice last Monday because we have lost the unity for which those who died and those who risked their lives strove. We have lost it in the House. I hope that we can get it back, that the debate will enable us to do so and that many Conservative Members who share something of that vision will decline to support the Government in the Lobby tonight.

7.12 pm

Mrs. Marion Roe (Broxbourne)

As Chairman of the Select Committee on Health, I should first like to inform the House of what the Committee has been doing in connection with London's health service. Its members have not only conducted an inquiry into London's ambulance service and prepared a report, which is about to be published, but kept a watching brief on the implementation of the proposals in the Tomlinson report. We have taken oral evidence from Sir Bernard Tomlinson and his team, the Secretary of State for Health, Department of Health officials, Sir Tim Chessells, the former chairman of the London Implementation Group, and my right hon. Friend the Secretary of State for Transport when he was Minister for Health.

As our evidence-taking sessions are in public and frequently televised, we believe that the questioning of our witnesses provides the opportunity for greater understanding of the issues, both inside and outside Parliament. We shall interview my right hon. Friend the Secretary of State for Health tomorrow afternoon, when no doubt my colleagues will probe for further clarification and information on the controversial matter of London's health services.

We have visited many London hospitals on fact-finding missions—Bart's, Guy's, St. Thomas's, Kings College, Charing Cross, Westminster and Chelsea, the Royal Marsden, Queen Elizabeth hospital for children and Hammersmith. This morning, we visited the Edgware and Barnet hospitals. We have arranged to visit London hospital and St. Mary's, Paddington within the next few weeks. You can therefore see, Mr. Deputy Speaker, that the future of the national health service in London has an important place in the programme of the Committee, and we shall give it the focus that it deserves in the future.

As a Member of Parliament for a constituency in Hertfordshire, I am acutely aware of the reasons why so many reports have been commissioned on the future of London's hospitals—20 in all. Immediately before the war, the resident population of Greater London was nearly 9 million; today it is 6.9 million. Londoners have moved out of the capital to new towns, the home counties and beyond. It was deliberate Government policy to encourage a shift in the population out of inner-city areas.

I know from personal experience that those former Londoners now wish to receive high-quality health care where they live today, not where they and their families used to live. They do not wish to travel considerable distances into London for hospital services that are more expensive and less convenient than local services.

It has always been a bone of contention in Hertfordshire that, over many years, the NHS funding available through the regional health authority was being drawn into London, and that our area was underfunded as a result. In truth, there has been resentment that London's hospitals have taken more than their fair share in the allocation of resources. I make that point because I fear that that important aspect of the debate is frequently forgotten or ignored.

So often we hear only of complaint, accusations of failure and gloom and doom in relation to London's health services, yet some outstanding successes should be recognised—for example, St. Mary's NHS trust, covering St. Mary's hospital, Paddington. The trust has achieved a balanced budget for four years in succession. It has treated 57,023 patients in 1994–95—an increase of 2 per cent. on the previous year. It has cut the average waiting time for an operation to four months. It treated 8 per cent. more people as in-patients and day-care cases in 1994–95 compared with 1992–93. It has treated 40 per cent. more cardiac patients since 1992–93. It has taken 40 per cent. more kidney failure patients on to its end-stage renal failure programme, including dialysis and kidney transplant, since 1992–93. It has treated 15 per cent. more people in accident and emergency in 1994–95 compared with 1992–93. There has also been a 20 per cent. increase in ophthalmic accident and emergency cases. It has cut by 10 per cent. the number of non-clinical managers, although many are clinically qualified. It has appointed a woman chief executive, who was formerly the hospital's chief nurse.

The trust has introduced a number of successful innovative services at St. Mary's. For example, as one of the first hospitals in the United Kingdom to establish a general practitioner's service located in the A and E department, St. Mary's is committed to the increased effectiveness of that model of care. I am sure that you, Mr. Deputy Speaker, will understand that a mobile local population, many of whom are not registered with a GP, can gain access to appropriate primary care, and that GPs and hospitals benefit from increased co-operation and understanding.

St. Mary's has developed a number of new services provided on an out-patient basis and designed according to the needs of patients and their GPs. The new one-stop breast care service allows GPs to refer patients with palpable lumps to a clinic where they will be seen within a week. The multi-disciplinary approach incorporates a consultant cytologist, a consultant radiologist, a specialist breast surgeon, an oncologist and a specially trained breast care nurse specialist. It is designed so that patients are supported through the necessary steps to determine their condition. Tests are performed on the same day so that concerned patients can be reassured or treated as quickly as possible.

St. Mary's has undertaken a successful pilot to make pathology test results available immediately to GPs in the surgery. Using simple technology and incorporating existing equipment, an effective link has been tried and tested. That system will result in NHS savings where the need for duplicate tests by a hospital doctor and GP will be removed.

Cited frequently as a blueprint for other units, the minor injuries unit at St. Charles' hospital, which opened in 1993, is one of the first of its type. One thousand patients per month have used the new nurse-led unit, which offers quick and effective care.

St. Mary's has developed an innovative policy of integrated care pathways for individual patients, which ensures that patients can be discharged as soon as their condition allows and with a high level of follow-up care and treatment. A discharge planning group, which reviews and changes practices both within the hospital and in social services, has reduced lost bed days dramatically during the past two years. Not only does that benefit patients: it increases the number of beds available for new cases.

Patients are brought from across the United Kingdom, often using an air ambulance, to the very specialist paediatric intensive care unit at St. Mary's. The trust continues to pioneer care for very sick children and it commands an international reputation for excellence. It has demonstrated its commitment to that specialist service by investing to increase to six the number of PICU beds during 1995–96.

St. Mary's is a centre of excellence for the provision of care to cardiology patients and those requiring cardiac surgery. About 1,000 cardiac cases will undergo surgery during 1995–96 and they will receive a service among the best in the world. Patients wait an average of just two months for surgery. Care is patient focused, including a pre-admission visit where patients and their carers or family watch a video, meet nursing and medical staff and have an opportunity to share their concerns in a familiar and supportive environment. Surgery is followed through with a rehabilitation support group.

The trust has taken steps to increase the number of ophthalmology patients treated effectively on a day-care basis at the Western eye hospital. A newly formed department using highly trained, existing hospital staff to provide answers, advice and support to patients, visitors, carers, family, friends, general practitioners and purchasers has been set up. It includes a free phone care line. In addition, the trust has even managed to pay the nurses' pay award in full.

I believe that hospitals that achieve should be rewarded. It can be bad for morale when hospitals that seem to be profligate or inefficient are apparently rewarded with additional cash and support, while those that demonstrate tough management are not. When doctors and nurses make sacrifices and change working practices, their efforts should be recognised. We seem to hear not much good news about health services in the capital, but there are hospitals that have not only embraced the health reforms but have actually proved that they can and do work to the benefit of patients.

My Committee and I look forward to welcoming my right hon. Friend the Secretary of State before us tomorrow so that this debate can be further explored.

7.22 pm

Mr. Jeremy Corbyn (Islington, North)

The reality of life in London is that there is a long and frustrating wait for operations that involves great pain, causes stress to immediate family and friends, and means the loss of very many working days. The waiting list in London now totals more than 180,000. The health service in London simply is not working. The staff are strained to the point of breaking, while those desperate for an operation cannot get one.

The information provided throughout this debate and the numerous inquiries into London's health service leads to one inescapable conclusion—that the experience of most Londoners is of constant closures, threats and a decline in the local health service and the ability to obtain treatment from it.

Professor Jarman, who has frequently challenged both Government statistics and the Tomlinson inquiry, has provided information showing that 7,000 beds were closed between 1982 and 1990. More than 3,200 have been closed since 1990. In 1982, London health districts had 26,000 acute hospital beds; there are now only 17,000, with plans to close even more. The number of long-stay beds for the elderly has dropped to 6,000 and the number of psychiatric beds has been reduced by 3,000 over the past three years.

The list goes on and on—yet the Secretary of State heads blindly towards oblivion, telling us that somehow or other things are getting better, that it is all an Opposition plot, and that we exaggerate the problem. The problem is there, it is real and it is very serious.

The debate has been presented as though there is some competition between London and the rest of the country. There is nothing of the kind. We are not discussing the centres of excellence, the specialties or the fact that people have to travel to London for such treatment; we are discussing ordinary people with ordinary illnesses who need good hospitals. Those hospitals are constantly threatened with closure.

We must recognise that in London, as in the rest of the country, no real planning is taking place in the health service. It is impossible to plan if the health service is run by the pressures of an internal market economy, where the buck is passed from the Secretary of State to her junior Ministers, to the district health authorities, to the health service trusts and then back to the Department. The merry-go-round goes round and round. The London group of Labour Members recently interviewed the two regional chairs, but all they told us was that they were sending things back to the districts. Nobody takes responsibility.

When questions are asked of the Secretary of State, we are told that apparently no figures are kept centrally on anything any more. We are told to write to our health authorities, but they tell us to get in touch with the Secretary of State. They think that it is easier for us to meet her than it is for them to do so. Unfortunately, they have rather serious illusions about the power of parliamentarians.

The closures that we are debating this evening are tragic beyond belief. Many of my constituents in Islington, North and those of my hon. Friend the Member for Islington, South and Finsbury (Mr. Smith) use, love and cherish Bart's hospital—not just because it is 800 years old, not just because of its traditions and excellence, but because it provides a good service. The closure of Bart's is a monstrous act of vandalism. There is no other way to describe it. The same is true of other hospital closures.

The knock-on effect of the closure of Bart's is enormous. It has already been felt in casualty units, and in the waiting lists that are developing elsewhere. The same is true with the closure of Guy's, Edgware and the Brook. The closures are wrong, they are not necessary, and they do not even save money. Indeed, the cost of closure is far greater than any potential savings.

In previous debates, I have referred to hospital closures in my borough—for example, the Royal Northern hospital. Before I was elected to this place, there was a huge campaign to defend that hospital's casualty unit. One of the first pieces of correspondence I received as a new Member of Parliament in 1983 was from the then Minister, the hon. Member for Reading, East (Sir G. Vaughan), saying that the Government were withdrawing their previous undertaking to maintain the Royal Northern, and that it would be closed. The hospital has been closed, and the site sold for property development. It has not even been sold for social development.

There were pleas from the Islington Pensioners Forum and many other people to provide nurse-managed beds at the Royal Northern. Indeed, I raised the matter with the Minister during one of our previous debates. Nevertheless, the concerns and the demand were lorushed aside, the hospital closed and the site sold to the highest bidder. Of course, highest bidders are those who can afford to speculate with their money on property development; they are not elderly people who need somewhere with nurse-managed beds where they can recuperate from treatment. The opportunity to provide that service has now been lost.

We need to consider the problems facing the emergency service. I wrote to the Minister on 21 March requesting a meeting after cancer patients had been turned away from the Whittington hospital because the emergency service had taken over several wards at that hospital following the closure of Bart's, which had forced patients to look to the emergency service. The casualty unit is working at more than 100 per cent. capacity.

One morning recently, 16 people were waiting on trolleys to be treated—but there was even a waiting list to get on a trolley. Some nine people had to wait for a trolley even before they had to wait to be treated.

The Government always say that the alternative to overcrowding and to the pressure on hospitals is to develop primary care facilities. It is not either/or—we need hospital facilities and primary care facilities. We need more GPs, better GP facilities, better primary care and far better health education. We also need to understand some of the causes of people becoming ill, such as the number of homeless, unemployed or very poor people in London.

I speak proudly as a member of Unison, and I think that we must look at the work that is done by the staff in hospitals. Morale in hospitals is at breaking point. Ancillary staff and manual workers are earning less in cash terms than they were many years ago, and their jobs are put up for sale to the lowest bidder every so often as the contractors try to move in and take over their jobs.

One has to wonder who is running the health service, and in whose interests it is being run. An attempt has been made by the Secretary of State to break up national pay bargaining, and to tell local hospitals that they must fund 2 per cent. of the 3 per cent, nurses' pay rise. What is going on is simply wrong. We must look ahead.

The Secretary of State says that the Labour party has no policies on the matter. I shall tell her straight—we have a lot of policies on health. First, we must address the democratic deficit in the running of the health service in London. No one knows who the members of the district health authorities are. They are faceless people, who are carrying out the Government's policies. We need a democratic, Londonwide health authority, and the necessary planning which goes into that.

We must also look at the poverty which people in London face. One of the most interesting documents I have read recently was the chief medical officer for health's report on Camden and Islington. The report showed that the borough's mortality rate was 25 per cent. above the national average, and that the borough had higher rates of infant mortality, drug abuse and homelessness. That is not unusual to my borough, and it can be replicated in borough after borough across London. We need some understanding of the causes of ill health in London, which are in part the environment and in part poverty. The health service in London must be able to meet those needs.

I conclude by referring to a letter which I received from the Islington Pensioners Forum, which I believe was sent to many inner London Members of Parliament. The secretary of the organisation, Angela Sinclair, said: The pensioners have paid for the NHS through national health insurance all their working lives, and that they depend on it in their old age. They feel bitterly let down when chunks of the family silver are sold off. That is a plea to keep Bart's and the other hospitals open, and to develop a health service in London that we can be proud of and upon which we will he able to rely.

7.31 pm

Sir John Gorst (Hendon, North)

I acknowledge the need for reform, and there can be no doubt that it is necessary. But it must be done with flexibility, not rigidity. It is a difficult problem, and one might say that what is important is not so much what one does, but how one does it.

I do not overlook the importance of preserving the national monuments—the hospitals such as Guy's and Bart's. They have been described as international centres of excellence, but I personally regard them as medical cathedrals, because they attract talent from all over the world. Other hon. Members—particularly my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke)—are greater experts on Guy's.

I will concentrate my remarks on the accident and emergency department in Edgware general hospital in my constituency. I would like to confine my remarks to amplifying four points which I made on 5 April, to which the hon. Member for Hackney, South and Shoreditch (Mr. Sedgemore) referred.

When my right hon. Friend the Secretary of State answered questions on the London closures, I said that closing Edgware hospital was doing the wrong thing, in the wrong way, at the wrong time and in the wrong place".—[Official Report, 5 April 1995; Vol. 257, c. 1738.] At the outset, I shall make one concession—if that is the right word—to the Government. I recognise that they have addressed themselves belatedly to both the timing and the manner of the closures. They were important considerations, but they were not relevant to the central issues. Of course it was never right to scrap an accident and emergency department until something was up and running in its place. I welcome the Government's willingness to correct that. But we must recognise that that is a palliative, or perhaps I might say a sedative. It is not a concession.

However much of a delay there may be before the closure takes place, regardless of the improvements in ambulance performances, and taking into full account the expanded capacity at alternative hospitals, the very distance and remoteness of those hospitals remains an obstacle to people living in Edgware. In short, we are left with an insuperable argument against closure. The measures are being taken in the wrong place, and will affect the wrong people. That is why 40,000 petitioners have united with one voice against the proposals.

I have repeatedly tried to point out to my right hon. Friend that Edgware general hospital has certain unique features. I have pleaded and argued for 18 months behind closed doors that those features should be recognised. As we are now discussing the matter publicly, F may regret those discussions, but I make no apologies.

Edgware general hospital serves an area with special social problems, and that is why the outcry has been so loud and so angry, and may perhaps be so prolonged. People on low incomes live within walking distance of the hospital, as do a large proportion of elderly and disabled people, many of whom are housed in purpose-built accommodation because of their disabilities. A significant number of refugee immigrants from troubled parts of Africa, with their attendant health and language problems, are also housed near the hospital.

To force those hard-pressed citizens—few of whom have their own transport—to struggle to find medical attention in an emergency not a few steps away from their doors but up to an hour away is a blind and, in my view, insensitive form of planning. After all the Government's palliatives, postponements and assurances, people on low incomes and elderly people will still be living there, and onerous travel will still be something that they have to face. As there have been no meaningful concessions by my right hon. Friend the Secretary of State, I shall be voting against the Government tonight.

I am not impressed by the emollient Government amendments, which are couched in what I must describe as blandly seductive language. Beyond the confines of Westminster, the niceties of who tabled what, and whether the amendments were expressed in harsh or moderate terms, is immaterial. Through the media, everyone knows that the vote tonight is about whether certain hospital facilities will be closed or kept open. My vote will be for the latter. The provenance of the motion is of secondary importance to the achievement of the objective.

The debate is significant in two respects. First, are the Government going to prove to everyone that they really mean what they say about listening to people at the grass roots? In the case of Edgware, that means listening to what 40,000 petitioners have been asking for.

Secondly, we in this House must be responsive to something more than cost-efficiency and clinical factors. We must acknowledge the weight that must be accorded to ordinary people's fears, desires, prejudices and conveniences. We are their servants, not their masters. Through their taxes, they pay the bill for what we run up on their behalf. The demands of those who elect us may outstrip the economies which Ministers' deskbound advisers think prudent. Obviously, Ministers must heed such cautious advice as they receive but, in the final analysis, they must also balance and reconcile it with what ordinary people want.

I therefore end my speech with this observation: human beings, not balance sheets, come first.

7.39 pm

Ms Margaret Hodge (Barking)

For every London Member, today's debate is of critical importance. The blinkered destruction of the national health service in the capital, driven by dogma and devoid of common sense, will leave the people of our capital not with a first-rate health service fit for the 21st century, as the Government proclaim, but with a second-rate two-tier service, where money means more than lives, and where flashy computers are valued more highly than the Dr. Kildares of the past.

Like others, I listened to the Secretary of State on the radio yesterday morning when she talked enthusiastically about how the changes in London's health services have been driven by the needs of technology. The Opposition have called this debate because we want a health service that is driven by the needs of the people. That is the fundamental principle on which the health service was founded almost half a century ago, and we reaffirm that principle today. Technology should be the servant of humanity, not its master.

What do the Government's proposals mean to ordinary people? I am currently dealing with three tragic deaths in my constituency, which, on the face of it, could have been avoided had the health service not been ravaged and fragmented. That is shocking. I am just one Member of Parliament; I do not know how representative my caseload is, but never a surgery goes by without three or four people coming to see me with yet more desperate stories of delays and incompetence in the local health service in dealing with their health needs.

At its most devastating, there are the deaths. In January this year, a constituent, Maria Ayling, died tragically at her home in Barking. She was only 20, and she died of a deep-vein thrombosis in her leg. She had been desperately trying to get into hospital for nearly two months before she died. Had she been seen and properly diagnosed, her untimely death could have been avoided.

Last Friday, I met the chief executive of Redbridge Healthcare, along with Maria's father and his solicitor. The day after Maria died, a letter arrived from the hospital giving her an appointment. It is not just the hospital that is to blame in this case; what the chief executive said about that letter says it all about the state of our national health service.

Maria was given the appointment not because the hospital had finally realised that she needed urgent medical care, but because the purchasing authority had unexpectedly released more money so that more people could be seen and new appointments made. That appointment came too late for Maria. What an indictment. That tragic case well illustrates the current state of the health service in London. It is always worth while reminding ourselves of the human reality that lies behind the statistics, which is what the Government fail to do.

Tonight, the focus is on north London, but what is happening in north London is also happening in east London. It is a national scandal that the Government determine their programme of hospital closures on the basis of simply buying another Tory Member's vote and thus buying another discredited day in government. That is Tory decibel planning at its worst. It is not just the closure of the A and E services at Edgware that matter, but the closure of A and E departments across the capital. If it is wrong for one constituency, it is wrong throughout the capital, and all hon. Member have a duty to their constituents to vote with us tonight.

My constituency has no hospital. The Government closed Barking hospital, despite a vigorous campaign led by my predecessor, Jo Richardson. The borough of Barking and Dagenham has no hospital, as the other hospital was also closed by the Government, and soon we shall lose our next nearest hospital, Oldchurch.

Despite universal condemnation, Ministers have decided to go ahead with the closure of the A and E department at Oldchurch. Hon. Members on both sides of the House, including the hon. Members for Hornchurch (Mr. Squire) and for Romford (Sir M. Neubert), have said that they oppose that proposed closure. If they mean it, they will vote with us to-night. If they do not, their constituents will know that they are not prepared to defend the national health service in their areas.

Closing accident and emergency departments is the most disastrous and dishonest way for the Government to proceed. If the A and E department of any hospital is closed, that hospital is condemned to a slow and painful death. Most admissions come through the A and E route; if those admissions are stopped, under the rigidities of the market, unit costs will increase, and the hospital will price itself out of existence and be forced to close. The Government do not even have the guts to tell us the truth. When they close the A and E department at Oldchurch, Bart's or Edgware, they are passing the death sentence on those well-loved and much-needed hospitals.

"But ah!" the Secretary of State will say. "We're opening minor injuries units to serve local communities." Those are another con. The minor injuries units will not even he able to set a broken leg. If all they can do is stitch cuts, that service should be provided by GPs in modern surgeries, and it is no substitute for an emergency unit.

If the vote of hon. Members from north London has been bought by the promise of a minor injuries unit, they have been conned. The units will do nothing for those who need an emergency service. They will still have to travel much further; they will still be dependent on the inadequacies of the London ambulance service; and they will still be transported far from their homes and families, as doctors desperately hunt for an empty bed. Primary health facilities are simply not in place to take over the burden created by the closure of hospitals.

Let us look at the reality facing real people in real communities like mine in Barking. "Don't worry about losing Oldchurch," we are told. "There's always Newham, Harold Wood and King George's." This morning, I rang those hospitals to establish whether, on their most recent figures, they could cope. As we know, and as the Secretary of State persistently refuses to acknowledge, they could not cope on the Minister's guidelines for an acceptable occupancy level.

Newham hospital told me that its occupancy level is over 100 per cent. It had to open 46 extra emergency beds to cope with the pressure from Homerton, which could not cope with the pressure caused by the closure of Bart's. Havering hospitals are running at nearly 96 per cent. occupancy and, on Friday, King George's was running at 93 per cent. occupancy.

The knock-on effect of other closures in that chaotic and fragmented market will add pressure on those hospitals. For example, closing Bart's will mean added pressure on the London hospital, which will therefore have to push people towards Newham hospital from the west, while we add pressure on Newham from the east with the closure at Oldchurch.

Mr. Andrew Mackinlay (Thurrock)

Will my hon. Friend give way?

Ms Hodge

No, I do not have time.

Opposition Members do not deny the need for change in the pattern of health services in London. What we oppose is the headlong rush for change being pursued with such zealousness by the Secretary of State. There are simply not enough beds, and there is a critical and urgent need to stop, think and listen, before the Government destroy what we all value. Our plea to every hon. Member, and particularly to the Secretary of State, is this: take the medicine of listening; swallow hard, and do the right thing—and withdraw the inept, penny-pinching proposals to close yet more hospitals.

7.48 pm

Mr. Richard Tracey (Surbiton)

I have been involved in public life in London for a good many years now and I am pleased to speak in this important and serious debate. The subject has engendered a great deal of discussion in this Chamber and other parts of the House for a long time between my colleagues and me and the Secretary of State and her junior Ministers, so there has been no lack of serious discussion of the points behind it.

In studying the history of health discussion in this place, it is interesting to note that the subject of London health and London hospitals has been turned over for at least 100 years. There is on record a report on the subject from a Select Committee of the other place in 1892. As the Government's amendment to the motion on the Order Paper says, the discussion has been going on seriously for 80 years. In a recent letter to The Times, Lord Annan recollects very serious discussion going on for 30 years.

The fact which repeatedly emerges from accounts of that debate is that on all occasions there has been a strong argument for changing the pattern of health treatment in London—the hospitals and the primary care of our people. In an account that I have read in the past few days, a professor at the university of York who studied the subject concludes: the … problems … have remained largely unresolved for lack of political courage. Unfortunately, that message has been expressed to me many times by people who, although they may not be so passionately involved in the subject as hon. Members on both sides of the House naturally are, nevertheless realise that there has been a fundamental change in the population patterns in our capital city and in the various needs for treatment.

Unquestionably, the London hospital pattern suited the needs of the past. The large hospitals in central London were set up many years ago to treat serious ailments on behalf of the country. That is no longer the position. As many colleagues have said earlier, people now want to be treated closer to their homes and progress in the technology of surgery and in the technology of treating ailments has made that possible. That is at the root of the Government's health reform policies.

Tonight we are discussing the pattern of health care in London, and we must concentrate on that, especially those of us who are London Members, but we must also heed the cries of colleagues on both sides of the House—most of whom, admittedly, are Conservative Members—for resources to flow out of London to their constituents, who previously may well have been transported to central London to be treated at Bart's or Guy's or St. Thomas's or any of the other great hospitals.

Mr. Mackinlay

The Government are even closing accident and emergency departments outside London.

Mr. Tracey

There has been a change, as I said, in the pattern of treatment.

I do not believe that any Members of the House have sufficient knowledge to disagree with the President of the Royal College of Surgeons or the President of the Royal College of Physicians. They are on record as saying that, because there are now methods of day surgery, methods of cold surgery and various other forms of treatment for many ailments, allowing patients to be treated quickly so that they may leave hospital and return to their homes, we no longer need the vast number of acute beds that were previously required.

Therefore, conclusions have been drawn, in all the studies commissioned by the Government, including the one by Sir Bernard Tomlinson—backed up, incidentally, by Professor Jarman, who has been quoted by Opposition Members—that the pattern of surgery is changing and there may not be so great a need for acute beds as there once was.

The hon. Member for Thurrock (Mr. Mackinlay) made a sedentary intervention about accident and emergency departments. A wealth of study and research—carried out not only in this country but in other parts of the world, in war zones and in other large conurbations on the other side of the Atlantic and so on—shows that the pattern of accident and emergency treatment is no longer the same as might once have been considered necessary.

A fact which emerges from those studies is that one of the most important aspects is to bring paramedic treatment to the scene of an accident as soon as possible. Studies undertaken in the United States of America show that, when paramedics reach the scene quickly, with properly equipped ambulances—in London, paramedics do not necessarily need ambulances because there are high-powered motor cycles to take them to the scene of the accident—the treatment they administer at the scene can do a great deal more to help save a life or prevent serious injury and its consequences for those unfortunate people than simply sending an ambulance and rushing them to hospital as soon as possible.

The evidence is there. Documentation is in the Department of Health—I believe that it has also been deposited in the Library—showing that accident and emergency treatment of that newly researched type is more successful than maintaining a proliferation of A and E departments in every hospital throughout the capital.

The Government have suggested to my right hon. Friend the Member for Brent, North (Sir R. Boyson) and my hon. Friends the Members for Hendon, North (Sir J. Gorst), for Hendon, South (Mr. Marshall) and for Finchley (Mr. Booth), that the proposals for the hospitals in their constituencies may well solve many of the problems that they have rightly drawn to the attention of the Secretary of State. Obviously, that is a problem for them to resolve, and I have every sympathy with them in trying to resolve it in the best possible way for their constituents.

The hospital which treats my constituents and those of my right hon. Friend the Member for Kingston upon Thames (Mr. Lamont) is Kingston hospital, which has grown in stature and expertise in the past few years. There has been considerable investment in the maternity unit—£7.5 million in recent times—which is much welcomed by local people. A sum of £1.5 million has also been spent on the Royal Eye hospital unit in Kingston hospital. As part of the reforms, there have also been considerable improvements in primary care in our part of south-west London. Ninety-four per cent. of the population of the Kingston and Richmond health authority are now treated by general practitioners who are fundholders. We have the largest percentage of fundholders, who have accepted that important advance in health care, in our part of London.

The reforms must progress. They should be pursued with resolve by the Secretary of State, and thereby the health of London will be considerably improved.

7.58 pm

Ms Glenda Jackson (Hampstead and Highgate)

The hon. Member for Surbiton (Mr. Tracey) suggested that his constituents wish to be treated near where they live. That is also true for people who live in inner and outer London boroughs. They, too, wish to be treated near where they live.

I pay tribute to the hon. Member for Hendon, North (Sir J. Gorst), who was an example to every Member of the House in the way in which he defended so honestly and openly the interests of his constituents and, I thought, even more, the interests of some of his most vulnerable constituents.

That is true for all of us, because we are attempting to defend people who, in many instances, are suffering from illnesses that they do not understand or are recovering from accidents which, by their very nature, came upon them when they were unprepared. To exacerbate those people's concerns by possibly making them travel for treatment to an area that they do not know, which makes it difficult for relatives to visit them to offer comfort as they recover, acts against the basic tenets of medicine and health care.

The hon. Member for Broxbourne (Mrs. Roe), in her guise as Chairman of the Select Committee on Health, gave us a comprehensive list of the London hospitals that she intends to visit and listed the witnesses from whom the Select Committee intends to take evidence. I hope that the Select Committee will also find time to take evidence from a constituent who earlier today submitted a green card asking to meet me. When I went out to Central Lobby, she told me of her grave concern about the outcome of the debate. She works in the cancer department at Bart's hospital and I am afraid that I could not reassure her that the outcome of the debate would be that Bart's will continue to flourish and to serve people as it has done for 800 years. She is a dedicated worker in the national health service and she told me that what is happening within the NHS in London is "a disgrace", to use her words. She cited instances where people suffering from cancer have had to wait more than four weeks even for an appointment, let alone any kind of treatment.

I regret that my hon. Friend the Member for Islington, North (Mr. Corbyn) is not in his place, as he made a salient point about the availability of health care, which impacts on all hon. Members who represent inner London constituencies. He said that there is obviously a need for primary health care in London, but an equal need for hospital health care. He argued that the health care provided for millions of Londoners at accident and emergency departments should continue to be offered until primary health care facilities are up and running.

As he said, it is not an either-or situation. Undoubtedly, it could end up as a neither-nor one, because many people in London—possibly hundreds of thousands—are not registered with any general practitioner. They look to the A and E departments of their local hospitals for treatment. If those departments are closed, some of the most vulnerable people in London will be left without any health care at all.

Various figures have been bandied today about the actual population of London. Some Conservative Members have argued that, since 1979, which seems to be a watershed for some of them, the London population has fallen. The hon. Member for Kensington (Mr. Fishburn) made a valid point, however, when he said that the population of London is not just made up of those who are residents, but includes the vast influx every morning of those who work in our capital city. They, too, require health care and health services when they are in what could be deemed the city of London, even though they live outside it.

In the past few years, there has also been a great influx of people looking for work and for homes in London. In many cases they appear on no register or census. My constituency seems to have an increasing population of homeless men. In many cases their homelessness has been exacerbated by problems occasioned by drug and alcohol misuse. It is extremely difficult for them to obtain any kind of medical treatment unless they register with a GP. In many cases pride, foolish though it may be, prevents them from doing so. They can, however, use the facilities that are provided by A and E units.

My central concern undoubtedly rests with the hospitals in my constituency, the Royal Free and the Whittington. We hear about restructuring day by day—on occasions, it seems like hour by hour—including the closure of Bart's and the possible closure of the A and E department at Edgware. If such facilities are lost, the hospitals in my constituency will be expected to take up the slack. They will be expected to be able to provide services for the sick and those involved in accidents.

Camden and Islington health authority has been told by the Department of Health that, in the next five years, it must look to a reduction of £25 million in its budget. I have asked the Secretary of State directly where the money will come from to expand facilities, as will be necessary, at the Royal Free and at the Whittington and to pay for the additional staff, but answer comes there none.

I add my voice to those of other hon. Members who have urged the Secretary of State to call a halt to the seemingly mindless rush to change existing health care provision in London. As my hon. Friend the Member for Barking (Ms Hodge) has already said, we are talking about the treatment of patients—individual human beings. It is their needs that we attempt to serve through the NHS in London.

I regret that the Secretary of State is not in her place. Surely she can take on board what constituency Members from London hear day in and day out, not only from our constituents but from people who are daily at the sharp end of NHS delivery in London. They all say that there is something wrong with that service provision. Day in and day out, we hear that the NHS in London is under inhuman pressure and that, in many cases, it is beyond the point of restitution and is suffering from internal decay. We are told that it is failing to do that which it was set up to deliver and to which those people who have dedicated their lives to working in it are still committed: to make the ill well and to ease the suffering of those who, for whatever reason, are particularly vulnerable.

I urge the Secretary of State to listen. She has been asked by hon. Members on both sides of the House to listen to the people who know best—not just the patients who use the health service, but most definitely those people who provide that service.

8.7 pm

Mr. Robert G. Hughes (Harrow, West)

The hon. Member for Hampstead and Highgate (Ms Jackson) said that the health service was failing generally, but such characterisation is a great insult to the people who work in it. That has never been my experience of the health service when either I or my family have used it.

In the seven or so years in which I have been a Member of Parliament, I have seen improvements in NHS provision in my constituency. There are still some problems, which were highlighted today by the Opposition, but they have not offered us a shred of evidence that they have a policy to deal with those problems. One must warn the Labour party that shroud waving did it a disservice at the previous general election—it partly cost it that election—and that shroud waving does not win it any votes.

As we were told that this debate is a non-party political occasion—

Mr. Mackinlay

Eh?

Mr. Hughes

Yes, that is what we were told on the radio by the Opposition, who said that the debate was about the health service. Presumably that is why the leader of the Labour party did a photo-call at Bart's this morning and why the right hon. Member for Derby, South (Mrs. Beckett) made such a highly political speech. I therefore thought that I would look back at the last debate on the health service when the Labour Government were in power.

On 15 March 1979, there was a debate in the House during which it was revealed that 600 hospitals were dealing only with emergencies, nine had closed completely and 5,500 beds were out of action. That did not cause cries of alarm at the time because that was an improvement on the situation when the House had last debated the subject the previous November. That is what the Labour party did to the health service when it was in government—it closed hospitals, reduced nurses' pay and cancelled the hospital building programme. Labour party members have no standing in this debate.

I came to the debate wondering on what evidence my right hon. Friend the Secretary of State had based her plans to allow the closure of the accident and emergency department at Edgware. The subject has been covered disgracefully by the Evening Standard and by other media outlets. I heard a journalist on London News Radio say, "Doubtless the Secretary of State will provide an argument for the closure, if there is one." That is a disgraceful way to approach the debate.

I tabled a question to my right hon. Friend asking for the scientific evidence upon which she had based her decision. I put that evidence before the right hon. Member for Derby, South and my questions clearly caught her on the hop. The fact that she had not examined the scientific evidence proved the emptiness of her arguments. I think that that is a disgraceful performance by a leading Labour party spokesperson.

The review of that evidence is available in the Library of the House of Commons—it is not hidden away—so the right hon. Lady and her colleagues may examine it if they can be bothered. It talks about the relationship between the size of accident and emergency departments and clinical outcomes. If we are talking about providing the best possible health service, we must talk about clinical outcomes. What happens when people use the accident and emergency facilities? All the evidence suggests that more lives will be saved in the future when the changes are implemented. I put that point to the right hon. Lady, but she did not seem to understand it.

In 1992, the North West Thames task force suggested that accident and emergency departments with fewer than 50,000 new patients per year did not have the necessary throughput for cost-effective care. It said that departments should have the capacity to deal with at least 50,000 new attendances per year as smaller departments are unable to employ experienced staff at night and at weekends. I argue that this matter does not revolve around financial considerations; we must examine what happens when A and E departments are concentrated in one area.

The results of a survey carried out in Orange county in the United States indicated a severe reduction in the number of deaths judged preventable. Labour Members may read about it in the "Archives of Surgery"—which I think is rather more authentic than Labour party briefing notes read by Labour Members. [Interruption.] Labour Members should listen to this, because it is important for their constituents as well as my own.

In a one-year experience, trauma care in Orange county California, where patients were taken to the closest hospital, was evaluated and compared with San Francisco county where all trauma victims were brought to a single, centrally-located trauma centre. The survey concluded that 73 per cent. of the non-CNS deaths in Orange County might have been prevented if the patients had been taken directly to a trauma centre". That idea is not restricted to the United States; nor is it anything new. The hon. Member for Barking (Ms Hodge) suggested that the measures were being rushed through. It was first suggested in 1961 that there could be an advantage in changing the accident and emergency arrangements. That suggestion has been ignored many times since then by many Secretaries of State and I pay enormous tribute to my right hon. Friend for having the political strength and courage to carry through the reforms.

Residents in Edgware will be no more than five or six miles from an A and E department. I appreciate the traffic problems in that part of London and I will turn to that issue in a moment. Some £60 million is being invested to upgrade the Barnet general hospital.

A scare story has been circulated in my constituency that that will put extra pressure on the Northwick Park hospital. That sounds reasonable on the face of it, but it is not true. As was said earlier in the debate, 30 new beds have been opened at Northwick Park hospital this year and it is planned to open another 60 beds next year. Admissions through the accident and emergency department currently total 13,000 and it will have the capacity to deal with 16,500 admissions in April 1997—the date of the proposed changes at Edgware hospital.

In addition, Northwick Park hospital will employ more staff and the hospital is about to engage a second consultant in the accident and emergency department so that it has the expertise to enable it to realise the scientific evidence which indicates that large, well-staffed A and E departments will save lives.

I agree with the remarks by my hon. Friend the Member for Surbiton (Mr. Tracey) about the lamentable record of the London ambulance service. The Pinner ambulance station in my constituency answers only 60 per cent. of calls within 14 minutes. Anyone who is familiar with the Harrow and Pinner area knows why that is so—the ambulances are concentrated on what must have been a very good site for that area many years ago, but it is no longer suitable. We need to disperse those ambulances. We need to implement some of the radical changes—I must explain it in shorthand because my time is brief—adopted by the Northumbria ambulance service.

It has made enormous improvements and I am sure that the hon. Member for Newcastle upon Tyne, East (Mr. Brown) would confirm that fact. It has a first-class ambulance service, which is measurably the best in the country. If it is good enough for Northumbria, it is certainly good enough for London. I hope that the ambulance service will introduce radical changes and use the extra money wisely. The service would benefit from employing paramedics on motor bikes who would get medical assistance and equipment to accident victims quickly.

8.17 pm

Mr. Stephen Timms (Newham, North-East)

Six months ago, when we last debated the health service in London, I raised concerns about the future shape of community health services in east London. At that time deep anxiety was expressed about the proposal to have a single trust-run community health service for Newham, Tower Hamlets, Hackney and the City. I was delighted when the Government announced at the beginning of December that there would be three separate trusts, and I welcomed the Government's response to the points that were made during the debate.

We were anxious that there should be separate trusts in order to expose how much money was being spent in each of the three areas. Our suspicions about funding disparities were confirmed when advertisements for senior positions in each of the new trusts were published. The published budget for Newham per head of population was less than half of that for the rest of the area. That fact highlights the issue of health service funding in London upon which I shall concentrate my remarks this evening.

The Government's amendment to the Labour party's motion on the Order Paper commends the Government for its record in investing in … the long-term interest of … the people of London; That choice of words betrays a complacency which rings very hollow all over London. There is growing and compelling evidence, including work commissioned by the Government, that areas such as Newham are deeply under-resourced and yet are still being cut back further in the allocation of national resources.

Two weeks ago the King's Fund published a report, called for by the former Government chief medical officer, entitled, "Tackling Inequalities in Health". The report's conclusions were forthright and unequivocal. It says: People who live in disadvantaged circumstances have more illnesses, greater distress, more disability and shorter lives than those who are more affluent. It continues: During the 1980s social divisions accelerated at a rate not matched for such a sustained period by any other rich industrialised country. Not surprisingly, the impact that this increase has had on health is now beginning to emerge. Death rates in some of the most disadvantaged areas in Britain not only worsened in relative terms between 1981 and 1991 … but among some age groups, such as young men, the death rates actually rose. That cannot be accepted as just an unfortunate fact of life. It must be addressed by those responsible for the health service.

The King's Fund report also says: The injustice could be prevented but it will require political will. The situation could be substantially improved if the political will existed to recognise that tackling inequalities in health is a fundamental requirement to social justice for all citizens. The question is: can British policy makers rise to the challenge? We cannot afford to ignore that challenge. The spiral of poor health and under-achievement cannot be allowed to continue. The social and economic costs as well as the moral responsibility will he borne by us all.

In October, the Centre for Health Economics at the University of York reported to the Government on the distribution of health resources. Its findings were unambiguous. It said: The current formula (introduced in the early 1990s) has resulted in a shift of resources away from the poorer and sicker areas. The York report produced a new capitation formula which would yield a significant shift of resources to the inner cities.

Tragically, the Government's response has been to water down that report and we are now told that in my area of east London we are to lose out even further when the Government's adaptation of the formula is fully in place. We will lose out by £14 million in a budget of £322 million. The pattern is the same elsewhere in inner London. It is a travesty of the York report's recommendations and the figures show that the Government are moving in the opposite direction to that recommended by the York team.

There is a crisis in the health service in London. Departing general practitioners cannot be replaced. In our accident and emergency unit at Newham general hospital, only seven of 11 vacant posts could be filled in the last recruitment round. The work load for many health workers is far greater than would be tolerated in more prosperous areas. There is a shortage of children's nurses, and orthopaedic wards have to rely on agency staff.

I want to raise deep concerns about what has happened to the funding that has been earmarked for primary care improvements in east London. The Secretary of State made a great deal about the need to redirect resources into primary care. We all welcome improvements in primary care and there is no doubt that, by one means or another, the Government have made some funds available. What has become of that money? Where are the improvements that it is supposed to bring?

I have with me an astonishing document. It is the latest district audit management letter on the City and East London family health services authority—the body that is charged with the responsibility for overseeing the primary care improvements that the Government have promised in east London. Those improvements are, without doubt, desperately needed. The document talks about the affairs of the authority and it says: there have been clear failures to recognise that there are legal limits on the powers of the FHSA … there have been instances where officers have maintained unofficial bank accounts in respect of FHSA funds … little regard was given to recommendations at audit for improving the management and financial affairs of the authority. Those serious allegations are documented in the report, which goes on to conclude that such failures have resulted in the consequent loss of scarce resources to health services in the area. The document tells us that significant sums of money have been wasted.

I am aware that there have been personnel changes at that FHSA, but it has shown itself wholly unable to oversee the capital projects that the Government have required it to deliver and which the Government have promised to the people of east London.

The Star Lane medical centre in the constituency of my hon. Friend the Member for Newham, South (Mr. Spearing) was allocated a grant of £1.9 million in the first year of the London implementation zone programme. Three years later there is no sign of a single brick being laid. I have tabled a parliamentary question asking where that money now resides.

This morning I received a letter from the Newham GP forum which says: We are at the bottom of a major recruitment crisis as well as suffering from rock bottom morale. The root of the problem is a catalogue of projects involving GP premises which have gone catastrophically wrong. The letter lists five of them. About one project it says that, because of his experiences with the FHSA, the doctor is on the verge of a nervous breakdown and bankruptcy. It says about another project: Despite this length of time and commitment no clear path has been agreed as to how these premises can be developed any further. That "commitment" involved a dentist putting in £150,000 of his own money.

About the next project the letter says: there is a strong possibility that recently started building works will be stopped before completion because the doctor's bank has advised him that he has too much negative equity. Another doctor secured a promise of £700,000 towards the cost of the premises from the London Docklands development corporation, subject to the work being started by 1 July this year. The letter states: there is no likelihood of any building works commencing before the deadline and as a result the whole project may have to be shelved. The letter adds that if that happens the doctor has decided to leave his practice, and Newham.

That is a catalogue of appalling mismanagement. Far from improving primary health care in east London, it is literally wrecking it. Those charged with delivering the improvements have been wholly incapable of doing so. I call on the Secretary of State to make an urgent and thorough investigation of what has happened to the London implementation zone funding for east London, because I am increasingly worried that terrible damage has been done.

8.27 pm

Mr. John Marshall (Hendon, South)

I have been amazed by some of the speeches in the debate. When my right hon. Friend the Secretary of State was speaking, some hon. Members from outside London were suggesting that the health service in London was somehow overfunded. I do not believe that that is true. For example, there is a 23 per cent. shortfall in psychiatric beds in London. One has only to look at the performance of the London ambulance service, which, by common consent, is the worst in the country. If one looks also at the difficulties that sometimes affect the supply of intensive care beds in London, one recognises why people in London do not believe that the health service is overfunded.

For colleagues from outside London to talk as if the health service in London is overfunded does a disservice to the debate, because it is not true. It was true in the 1970s when the then Labour Government instituted the resource allocation working party formula, which affected resources in London in the late 1970s and throughout the 1980s. Now those resources have been removed. It is wrong for people to recycle the speaking notes that they have used for the past 20 years and assume that they are still accurate. I know that in politics it is a great temptation to do that, but we should not seek to follow it.

I heard one comment about Edgware, which suggested that the hon. Member concerned probably did not know either its geographical location or even how to spell it. He suggested that it might be in central London.

When the Secretary of State announced in a written answer that she had approved the closure of Edgware accident and emergency department, I subsequently made a number of points. I said that she was proposing a system of primary health care whereby most of the extra £15 million would be spent after the Edgware accident and emergency department was closed, which seemed unacceptable.

I am pleased to say that this afternoon the Secretary of State has come to the House and agreed to spend an additional £2 million—as I understand it, £1 million this year and £1 million next year—mainly in the western part of the London borough of Barnet, which includes a significant amount of my constituency. Obviously, it is difficult to be too beastly to a Secretary of State who has this afternoon given some money to my constituency.

However, I have a number of questions that I want to ask about the other four issues that I have raised with the Secretary of State. The first involves the London ambulance service. We are told that there will be two additional ambulance crews in the Edgware district. We are told that the London ambulance service will continue to be monitored against the patients charter standards. If the London ambulance service fails to meet those patients charter standards—

Dr. Ian Twinn (Edmonton)

If it continues to fail to meet them.

Mr. Marshall

As my hon. Friend says, if it continues to fail to meet those patients charter standards, what will the Secretary of State do? Will further additional resources he put into Edgware? Will there be a radical reorganisation of the London ambulance service, or what?

I have raised the issue of transport links with the Secretary of State on a number of occasions. This afternoon she said that she was setting up a working party-50 per cent. of that working party is sitting on the Government Front Bench and the other 50 per cent. is to come from the Department of Transport.

Transport links between Edgware and Barnet are particularly poor. During the Easter recess, my hon. Friend the Member for Chipping Barnet (Mr. Chapman) and I were due to meet the chairman of the Wellhouse trust at Barnet. We arrived on time at 2 pm. The chairman arrived at 2.15 pm and said that the trouble was that transport links between Edgware and Barnet were not what they should be. I understand that my hon. Friend the Member for Finchley (Mr. Booth) had a similar experience and was kept waiting even longer. The chairman was not trying to be discourteous or to prove a point, but the point was very well made. I am glad that the Secretary of State is setting up a working party.

We have a right to know when that working party will report. Will it report to the House? How will we hear what it decides? If it recommends significant expenditure, it might be open to the Secretary of State to reopen the issue of the closure of the accident and emergency department at Edgware because, if a lot of money is to be spent on roads, further questions must be asked.

We are told that the minor accident unit at Edgware will be opened as soon as possible—it will be opened in 1996 rather than 1997. That is of benefit, in that it will be up and running before any closure takes place. We have been told in a letter from the Secretary of State that there could be a general practitioner presence in the minor accident unit, which is currently expected to be solely a nurse-based unit. We should like to see that possibility fleshed out. We should like to know how likely it is that the unit will have a GP presence rather than just a nurse presence. That is an important question that must be answered, as the matter will clearly be of concern to us over a considerable period.

Everyone who knows me well knows that the past few weeks have been particularly painful. I think that even the Government Whips Office would accept that I am normally a loyal Government supporter. I have rebelled only twice: once over the social security reforms in 1988—

Dame Elaine Kellett-Bowman

Twice?

Mr. Marshall

I should remind my hon. Friend that the Government changed their mind within 10 days of my rebellion, so I was right. I rebelled for a second time in 1989 over the Football Spectators Bill and again I was right as the Government tore up the Bill, so I shall not take any lessons from my hon. Friend about when I should and should not rebel. I accept that, in the role that I have held for some time of parliamentary private secretary to one of the most decent and nicest men, I have had obligations.

I hope that never again will announcements about Edgware hospital be made by way of written replies on the day before Adjournment debates on the future of that hospital. Such a procedure was discourteous to my hon. Friend the Member for Harrow, East (Mr. Dykes), who instituted the debate.

I believe that this will not be the end of the saga and I suspect that it will be revisited from time to time. This evening, in view of what the Secretary of State announced earlier, I am minded to support the Government. But before my hon. Friend the Member for Lancaster (Dame E. Kellett-Bowman) gets too broad a grin on her face, I should tell her that if her grin becomes much broader, I certainly will not support them.

8.36 pm

Mr. Harry Cohen (Leyton)

There is an enormous amount of public anxiety and anger at the consequences of the mishandling of the national health service in London. Some of the blame is put at the door of the managers, but most of it is laid at the door of the Secretary of State for Health and the Government.

I pay tribute to the few hon. Members who have spoken out and stood up to be counted tonight. They made eloquent speeches, fighting for their constituents and for London hospitals. They made a good point when they said that the Secretary of State refuses to listen to the concern of Londoners and refuses to acknowledge the reality of what is going on in the health service. I shall give some examples of the realities.

Casualty Watch recently published a report stating that it carried out 11 spot checks in London hospitals between April 1994 and February 1995. It found that more than 170 people had been waiting more than five hours on trolleys in those London hospitals and that most of those who were waiting were elderly. It even found one woman of 101 years old who had been kept waiting for six hours at Queen Mary's university hospital in Roehampton in January this year.

I have taken up the issue. In late February, I complained that my hospital of Whipps Cross had a shortage of hospital beds and a shortage of trolleys. That shortage meant that patients were left on the ambulance trolleys that had brought them, thus tying up 10 ambulances that would be needed in an emergency. The chief executive of the Forest Healthcare trust said that the hospital was overwhelmed.

Waltham Forest community health council has just published a report giving examples of the crisis in the district. It stated that one woman who had a burst appendix was a priority 1 patient; she had a four-hour wait to see the doctor. She was in great pain and had to wait a total of seven and three quarter hours before she was found a bed. Another woman with a priority 2 illness was finally treated after a nine-and-a-half hour wait. An elderly woman with diabetes who had recently had a triple bypass operation was seen briefly by a doctor after half an hour, but she was then left on a trolley for seven and a half hours without any food or drink.

Another case involved an elderly disabled woman who had a nine-hour wait for a bed. Three months later, she went back to the accident and emergency unit with pleurisy. On that occasion, she waited 12 hours on a trolley for a bed, which eventually was not available, and she was sent home.

Those are just four examples in a recent report from my local community health council. It points out that Whipps Cross has one of the busiest casualty departments in the country, with more than 80,000 patients. The number of patients has increased by 3,000 in the past three months because of the closure of Bart's accident and emergency department and the knock-on effects of that; there has also been the staff shortage that was mentioned by my hon. Friend the Member for Newham, South (Mr. Spearing).

The CHC takes apart the official patients charter, to which the Government keep referring, to say how wonderful things are. It says that the official patients charter statistics disguise the major problems patients face when using A and E services. It goes on to say: it is claimed that 97 per cent. of patients at Whipps A and E have an 'initial assessment' within five minutes, but this does not acknowledge that they then have to wait for a proper assessment to be carried out. That can take one hour. Official Forest Healthcare trust figures relating to patients in each priority group seen by a doctor show that 78 per cent. of priority 1 patients are seen within two hours, 82 per cent. of priority 2 patients are seen within four hours, and 84 per cent. of priority 3 patients are seen within four hours. My CHC asks, "What of the patients who are not seen within those times—how long do they wait?" Even after being seen by a doctor, a patient may wait hours for further attention because of the pressure of work on the A and E Department.

Several hon. Members have referred to the London ambulance service. We all know that it descended into a shambles when the computer broke down. Many of us would blame the Government in their pressure to privatise the service. Whatever the situation, let us look at the current position. Mr. John James, who is responsible for the service, has written to me saying: Overall, the total cost of the emergency services has risen from £63.9 million in 1994–95 to £82.2 million in 1995–96, an increase of 28.6 per cent. However, because £4 million in 1994–95 was met from central funds in 1994–95, which were not made available in 1995–96, the overall increase in cost to DHAs was 37.2 per cent. That means that district health authorities in London have had to find an extra £22.3 million from their hard-pressed budgets to pay for that London ambulance service shambles and to try to get the service back into order. That £22.3 million has been taken out of patient treatment in London, whereas the Government should have provided that money.

The hon. Member for Hendon, South (Mr. Marshall) talked about the £2 million for Edgware that has bought his vote tonight. A couple of million will come out of patient care in Edgware and in Hendon to pay for the London ambulance service. The money with which the hon. Gentleman has been bought off has been swallowed up very quickly. [Interruption.] That certainly is true. I have done a survey and I can show hon. Members the results.

The House of Commons Library presented for me figures that show that 83 hospitals in London have closed between 1979, when the Government were first elected, and March last year. On top of that, there have been a large number of accident and emergency unit closures. Many more are in the pipeline. All that has occurred without any publicly stated Government policy or anybody's policy on accident and emergency provision in London. Those closures are carrying on apace because trust managers regard them as the best way of further reducing acute beds in their areas. A and E closures are financially driven.

Our vote tonight is the last chance for London Members, particularly Conservative Members, to save the health service in London, particularly A and E provision in London. Even if some A and E units are not under threat now—and many of them are—the Government will come for hon. Members' accident and emergency units if they carry the day.

In the 1980s, the Government said—they have continued to try to use the phrase—that the health service was safe in their hands. There comes a time when that phrase must be proved, and we shall find out tonight. We shall discover whether the Conservatives can stand by it. Unless London Conservative Members show courage, as some who have spoken tonight have done, a significant proportion of the NHS in London will slip like sand through our fingers.

8.45 pm

Mr. Roger Sims (Chislehurst)

I have previously commended my right hon. Friend the Secretary of State for her courage in tackling the issue of London hospitals, and I do so again today. The amendment refers to the 20 or more reports that have recommended action that is clearly overdue. The action that was needed my right hon. Friend has initiated. To bring everything to a complete halt now, as the motion appears to demand—indeed, those were the words of the hon. Member for Hampstead and Highgate (Ms Jackson) a few minutes ago—seems to me to be unacceptable. If the Opposition thought that the wording of their motion would seduce me into supporting them, they have failed.

Of course, these are matters in which, whatever decisions are taken, some people will be upset. Every hospital has a loyal following of local residents, patients, general practitioners, doctors and nurses at the hospital, and doctors and nurses who have trained there and perhaps have moved on. If we always bowed to all their wishes, there would never be any changes. But, if it is proposed to close a hospital or substantially to change its character, there must be a process of consultation. That, surely, is a moral obligation as well as a legal obligation. Consultation surely means listening to the views expressed and considering them, and not being averse to responding to reasoned arguments.

The Secretary of State and the Minister for Health have their advisers—political advisers and medical professional advisers—but they should take account, too, of what may be different advice offered by others who are as well qualified professionally and of those who are as able, if not better able, to reflect the views of the communities affected, including, of course, local Members of Parliament. I fear that that is not always done. My right hon. Friend enjoys my admiration as a most able, enthusiastic and dedicated Secretary of State, but a Minister must also be a politician, and in politics one is more likely to get things done if one listens to what people have to say and tries to take them with one.

My concerns, as the House will be aware, are with the proposals concerning Guy's and St. Thomas's hospitals. Let me make it clear that the issue is not about spending money on those hospitals in inner London as against expenditure further outside London or in the suburbs. Indeed, I shall want the Bromley hospital trust to be given adequate resources to enable it to develop a new hospital on the Farnborough hospital site. In this case, the issue is not about closing down complete sites, because both sites will remain open.

It is certainly not a Guy's versus St. Thomas's contest. The issue is the need to obtain the best possible use of limited resources—that is buildings, equipment and staff. It is, to quote the words of the Secretary of State in a letter that she wrote to the hon. Member for Southwark and Bermondsey (Mr. Hughes), to ensure the most efficient and clinically coherent balance of services between its sites". On 29 March, when the consultation process was completed and the proposals were on the Secretary of State's desk awaiting a decision, I secured a Wednesday morning debate on Guy's hospital. I summarised the original and final proposals for the two hospitals and the consultation process. I spoke of the work of the Save Guy's Hospital Campaign, of which I am joint chairman. 1 outlined our concerns and raised a number of issues.

A week later, the Secretary of State announced that she was confirming the proposals without modification. Of course I accept her word that what I and others said in the debate was read and considered, but I am sure that she will understand that some people have the impression that our words were completely ignored. Personally, I was surprised that no attempt was made to answer the points that were raised in the debate before the decision was announced. I have since had a letter from my right hon. Friend, but some of the issues remain unresolved.

It would be unreasonable of me to repeat the speech that I made on 29 March, even if time allowed, which it obviously does not, but the Government amendment invites me to call on the Government to ensure that their decisions on London hospital services are carried forward.

If I subscribed to that, I would be endorsing, among a number of other propositions, first, leaving the City of London and its 300,000 daily commuters—some of whom are my constituents—after 1998 without any accident and emergency facilities to deal with another Cannon street train crash or Bishopsgate bomb outrage; secondly, not using to the full Philip Harris house for the purposes for which it was designed and built at a cost of £154 million; thirdly, using Guy's for day surgery, elective surgery and minimally invasive therapy without any intensive care facility on the site; fourthly, the separation rather than the integration of out-patient and in-patient services for specialties such as renal, oncology, cardiology and ENT; and, fifthly, I would be endorsing the expenditure of £90 million on new building and refurbishment at St. Thomas's to accommodate the services moved from Guy's, while leaving some 19 floors or 35,000 sq m of unused space at Guy's.

I cannot in all conscience endorse such plans, so the House will understand why I shall not support the amendment which calls for their implementation.

8.52 pm

Mr. Andrew Mackinlay (Thurrock)

I consider that Londo3's hospitals are underfunded and I appreciate all the arguments advanced by hon. Members representing part of Middlesex and London in respect of the Edgware general hospital. Before I came to the House, I worked in Golders Green for 12 or 13 years and I empathise with local people who appreciate and want to keep the accident and emergency department open in Edgware. I shall return to that in a moment.

The motion refers to London's health service. Strictly speaking, there is no such thing: there are two regional health authorities. My area of Essex is part of the North Thames region and in the context of today's debate I would argue that it is part of London's health service.

I am unique inasmuch as I am the only Opposition Member representing Essex and the counties that skirt London or the M25 ring. I can legitimately claim to speak on behalf of those constituents who are not represented in the Chamber at the moment, except by the Government Whip, the hon. Member for Chelmsford (Mr. Burns), who has to remain silent.

We listen to the Government's argument that the closures will provide additional resources for counties outside London, but that is not the experience of my constituents and those who live in areas surrounding London. Frankly, we do not believe the Government. [Interruption.] Somebody from a sedentary position said, "Rubbish," but my constituency of Thurrock endured the pain and anxiety of losing the accident and emergency department at Orsett hospital.

Regrettably, only when the closure of the accident and emergency department at Edgware general is proposed, or hon. Members representing Westminster and the City are aggrieved, does the House pay attention to a crisis that is not peculiar to the old GLC area, the boundaries of which resulted from a decision made in the House of Lords at 2 am in 1963 and which do not represent "London" in the context of this debate. London is much wider, especially with regard to health provision.

Conservative Members are aggravated by the political fallout that was demonstrated in stark terms last week. As we approach a general election, they want to distance themselves from the Government's policy of cuts in the national health service. They did not speak up when the accident and emergency department in my constituency was closed or when accident and emergency departments were closed elsewhere around the M25 ring.

It is time to make it clear that the Government are cutting hospital provision for many people in London and elsewhere. I heard all the arguments advanced by the hon. Member for Hendon, South (Mr. Marshall) excusing why he would not support the Opposition motion tonight but would sustain the Government. They involve palliatives and promises that extra facilities will be provided as compensation for losing A and E departments. They are not worth the paper they are written on.

I should say, as a lesson for other hon. Members who are considering supporting the Government, that when our accident and emergency department was closed in Thurrock, we were assured that the rest of Orsett hospital would be maintained. They were solemn and binding undertakings, but a few months ago it became clear from a leak that they intended to close the whole hospital.

My constituents and others joined in a massive campaign to retain Orsett hospital, or what was left of it. We succeeded, but we do not believe that that will the prevent faceless men and women who run our health authorities and the trust from again trying to close totally our Orsett hospital.

I use my constituency as an example of what could happen elsewhere. It is in the fastest growing area of south-east England outside London—the Thames gateway—yet the madness of Government policy and their lack of planning led to an attempt to close our hospital.

My constituents now have to travel to Basildon to get hospital care, which has put an inordinate extra burden on Basildon and other hospitals. My hon. Friend the Member for Barking (Ms Hodge) described how Oldchurch hospital would close and put extra demands on Harold Wood hospital. Since my local accident and emergency department closed, my constituents are putting extra demands on Harold Wood hospital, because that is one of the places where they are taken by bus or ambulance to receive accident and emergency and other treatment. It is foolish that this policy should be allowed to continue.

The motion calls for a halt and a major review. That is prudent. It would be appropriate to encompass in any review everything in an area wider than the old GLC area—everything around the M25 ring—as we are as vulnerable to the cuts as elsewhere.

There has been some commendation of the few Conservative Members who have said that they will not support the Government tonight. I join in that, but there is a danger of going over the top and implying that the hon. Member for Hendon, North (Sir J. Gorst) is equivalent to the Archangel Gabriel. I give him full marks but where has he been all this time? He is faced with the closure of an accident and emergency department on his own doorstep now, but he would not have dreamed of supporting me in defending the A and E department at Orsett. I do not suppose that he knows where Orsett is to be found.

If Conservative Members generally are concerned about the thrust of Government policies, they must support the Opposition motion so that the Government will pause and rethink the totality of the policies on which they are now embarking. I do not know whether it was implied or said by an Opposition Member on radio this morning that this is not a party political matter. If so, I dissociate myself from that remark because it is party political. In the months leading to the next general election, I shall unashamedly point the prosecutor's finger at Conservative Members who do not join us in the Lobby tonight. They are all the same and they are all to blame by acquiescing through their silence in a rundown and haemorrhaging of the NHS in and around London. It is time to spell that out without ambiguity.

I cannot find words to describe the lasting resentment among my constituents at the Government's deceit and betrayal over hospital care. I include in that the people of Basildon, whom our loss at Orsett also affects. My constituents now have to be sent to Basildon hospital and endure inordinately long waits on trolleys and in the casualty department. In addition, many of my constituents are taken not only to Harold Wood hospital but across the River Thames to Kent, such is the absurd lack of planning.

I welcome being able, perhaps for the first time, to muscle in on something that is wrongly described as a "London debate": it goes much wider. It affects people in Harlow, Basildon, Thurrock, Gravesham, Dartford, Slough and other constituencies around the London area, which are not being properly represented in the House, and whose national health service is not being championed by Conservative Members.

9.2 pm

Mr. Hartley Booth (Finchley)

It is a pleasure to follow the hon. Member for Thurrock (Mr. Mackinlay) who, as usual, was robust in his remarks, and on this occasion robustly wrong.

The debate has been characterised by a mirage of the past, suggesting that the health service in London was always better then—a sort of never never land of wondrous results. In fact, we are dealing with the same problem that has existed for hundreds of years.

Liverpool Street and Broad Street railway stations are built on the foundations of a medieval hospital that was well known at the time. Some people might think that it would have been better if it had been kept as a hospital. A retired doctor from St. Thomas's reminded me that 30 years ago patients were left on the floor in a crisis. Only in 1968 was the first accident and emergency consultant in the country appointed. Today, such consultants can be found everywhere. We have been improving, and we should put that fact on the scales tonight.

The Opposition motion criticises the closure of accident and emergency facilities in London, while the Government motion stands for new and better services and says that the Government—will take due account of concerns. I hope so. I do not accept that the description "closure of … facilities" is apt, accurate, balanced or fair in respect of Barnet. A new hospital costing £61 million is being built, and we are promised that a new casualty unit will be kept open in Edgware. However, I shall be making some demands of my right hon. and hon. Friends on the Front Bench.

Edgware hospital is being kept open, and there is a list of improvements for the new area trauma centre to be built at Barnet General hospital, costing £1.5 million. It will offer a major treatment room with greater availability of specialist piped medical gases, decontamination showers and a sound attenuating examination room. The "physical specs", as they are called, state that the centre will be 250 per cent. larger than the present A and E department. There will be an operating theatre for major trauma, diagnostic imaging and a pneumatic tube system—all costing an arm and a leg in more senses than one.

I asked an orthopaedic surgeon at Barnet General for his thoughts on the centre. He welcomed it. He had possibly wanted a new hospital situated midway between the two existing hospitals, but he is grateful and delighted that there will be a new hospital in Barnet—not least because he currently has to travel between Edgware and Barnet in rush hours and in crisis situations. I shall refer to transport later, if there is time. At present that consultant has to cover two hospitals.

Do we want to retain the A and E department on the same basis as at present, as suggested by my hon. Friend the Member for Hendon, North (Sir J. Gorst), whom I deeply respect? No—we want to improve on that situation. Are we against all change? Of course not. At present, there is an orthopaedic consultant only at Barnet General and none at Edgware, and there is no maternity department at Barnet. That cannot be left as it is. There must be change.

Safety is paramount, as was mentioned by my hon. Friend the Member for Harrow, West (Mr. Hughes). The Royal College of Surgeons states that 25 per cent. of all deaths in A and E departments are avoidable. I could not have deaths on my conscience, so I must speak out tonight to say that such deaths are avoidable if we have the improved A and E departments that our new hospitals and constituents deserve. We must satisfy the public's fears.

How do we do that? I have been fighting for better transport links across the A1, which is a huge physical barrier. I am grateful to my right hon. Friend the Secretary of State for saying that she will bear that in mind. We shall be watching for such improvements. We certainly do not want people dying en route to hospital.

I hope that the Edgware injury clinic—the new casualty department, as the chairman of the local NHS trust calls it—will not only have 80 per cent. of current casualties, but that it will be supported by general practitioners, not just nurses or paramedics. We need better transport links and I am glad that we have improved community medicine, to which my hon. Friend the Member for Hendon, South (Mr. Marshall) referred. On behalf of the people of Barnet and Finchley, many of whom cross the A1 to Edgware, although many more go to Barnet, I thank the Government for the new hospital that we are getting. It would be niggardly not to be grateful for it. We shall keep Ministers to the four promises that we have heard today. We shall be watching.

We ask what Labour, whose debate this is, would be doing. Would it reverse the decision over Bart's? Would it reverse the decision to give us a new hospital in Barnet? Would it keep Edgware open? Answer comes there none. The Labour party is vacuous in the absence of real answers to difficult questions in this area. Literature has been quoted to us this evening by my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke). I will quote Shakespeare: the Labour party is full of sound and fury, Signifying nothing.

9.11 pm

Mr. Clive Soley (Hammersmith)

I offer my apologies to the House for having missed the first part of the debate. I am Chairman of the Select Committee on Northern Ireland, which has been taking evidence this afternoon.

I want to speak, if only briefly, on a number of matters. First, I wish to make a point which I suspect may have been made before, so I shall therefore make it briefly: the fundamental problem with the Tomlinson report was that it did not take into account the impact of outer London on inner London. One of the powers and strengths of Professor Jarman's report was that it recognised that inner London could not be treated as though there were some dividing fence between inner and outer London. Once that artificial fence is taken away, the problem in London is seen to be not so simple as Professor Tomlinson's report made out. That is why things have gone badly wrong.

My second point, and one of the prime reasons why the Secretary of State is in such serious trouble, is that the main problem in the health service—one which has to some extent been there since the 1974 management changes, but dramatically more so in recent years—is the lack of an effective method of consultation. As a Conservative Member said, people felt that consultation was not working. That is certainly my experience in west London. The feeling is that things happen without a strategy. I acknowledge that the Secretary of State has said that she wants a strategy for health care in London, but the various community groups, including the community health councils and others who should be taken into the confidence of the hospital management structures, do not feel that they know what is happening or why.

The general feeling about consultation is that a paper is published, people are asked for their views, which they give, but at the end of the day the rubber stamp comes down reinforcing the original proposal without people's views and comments being taken into account in any effective way. Consequently, there is much anger and lack of understanding when decisions about hospitals' futures are made. A simple but dramatic example occurred in west London when the new Chelsea and Westminster hospital was built, massively over cost—more than £200 million. In retrospect, that was an incredible decision. Had it been made by a local authority, it would probably have led to councillors being surcharged.

The Secretary of State was then faced with the unenviable decision whether to close Charing Cross hospital or Hammersmith hospital. Charing Cross hospital was only 20 years old, but Hammersmith hospital is the world's premier postgraduate medical school with an immense reputation in Britain and overseas. Eventually, the right decision was made and the two hospitals were merged into one trust. However, that still leaves the question of what is to happen to the three large hospitals in west London. It is not that there is over-provision; rather there is under-provision in certain key areas. I receive the same sort of letters as other hon. Members about the lack of bed space and the lack of time for operations.

The closure of an accident and emergency department in effect means the closure of the hospital. That is why there is such concern—certainly in west London and, I suspect, elsewhere—that the purchasing authority, which in my case is the Hammersmith, Hounslow and Ealing authority, will choose to buy from only one hospital, perhaps Charing Cross, leaving Hammersmith, which has had less investment in its accident and emergency department, more vulnerable. If we get into the ball game in which the purchaser decides which accident and emergency department survives, in the long run the purchasers will make the decisions about which hospitals survive. That is not the most sensible way to proceed.

I suspect that psychiatric patients have not been discussed in any great depth today. In my area and, indeed, throughout the capital, the provision of beds for such patients is a major problem. Care in the community is clearly a good policy, which we all endorse—provided that the community facilities are there; if they are not, the policy becomes a disaster. In that event, there is no care in the community. There have been some horrendous cases in recent years.

The provision of housing, hostels and follow-up nursing care is vital, and the lack of psychiatric beds poses a major problem to the safety of patients and, indeed, the public at large. Some of the patients are very disturbed; some, though not all, are offenders. We should bear in mind that the regional secure units also feed into the system of care in the community. There is a human problem for the individuals concerned, but a drastic problem for the health service and the general public.

Let me say this to the Secretary of State: for heaven's sake start looking at a management system which is so secretive that people feel—rightly, in my view—that they do not know who is making the decisions, how those decisions are being made or how they themselves can have any impact on those decisions. The problem with the NHS, in this context, is that it is paid for by the taxpayer but the taxpayer knows virtually nothing about what is being proposed and how the money is to be spent. We need to think long and hard about the sort of management structure that is necessary in the health service to deliver an efficient health care system combined with accountability to the public.

Finally, I do not think that we shall have the morale in the health service that we ought to have until we provide a proper pay structure for nurses, midwives and other key groups who currently feel battered and undervalued.

9.16 pm

Mr. Hugh Dykes (Harrow, East)

Thank you for calling me at this late stage, Mr. Deputy Speaker. I appreciate it very much. Having launched an Adjournment debate on 5 April which lasted much longer than usual, and having made a long speech on that occasion, I do not resent the fact that others have spoken earlier than me today, and I am glad that the Chair made those selections.

It behoves me to say—as did my right hon. Friend the Member for Brent, North (Sir R. Boyson)—that I shall not be able to support the Government tonight after what I have heard so far. I am extremely disappointed that the Secretary of State was unable to make any significant concessions to alter the drastic position in which we find ourselves.

For geographical reasons, my hon. Friend the Member for Hendon, North (Sir J. Gorst) and I—with the permission, approval and support of our other colleagues—have led, for over a year, the great campaign to save the accident and emergency unit of Edgware general hospital from closure. The closure is proposed by the district health authority, and supported by the regional health authority. We continue to think that a grave mistake.

The position is not the same as that of the old central London hospitals—although I wish them well, and do not want them to be closed, either. This vital unit in an outer London borough is heavily used, efficient and popular; as my hon. Friend the Member for Hendon, North has said on many occasions, it is also part of a much-loved social institution. It is on the Edgware road, on the border between my constituency and that of my hon. Friend. If it is closed, the journey to Barnet, the Royal Free hospital in Hampstead or the Northwick Park hospital will be too long in congested traffic.

The Northwick Park hospital, incidentally, is the most important district general hospital in my area and the constituencies of Brent, North and Harrow, West. I wish it and its future development well; that does not contradict what I am saying about Edgware general hospital.

I am disappointed. During the last minutes of the debate, the Minister has the chance to make the additional concessions that we would require to support the Government tonight. I would not have any pleasure in supporting a Labour motion. I cannot remember the previous occasion when I did that. That is not the job of a Government-supporting Member.

I strongly support all the Government's policies, but we need extra movement, an extra concession and extra realism from Ministers. They should not respond only to the medical bureaucrats in their Department, whose easier solutions are to combine units to try to save accounting costs at the margin. Everyone can do that. It is not a particularly difficult exercise, despite the obvious complexities, but for the sake of all our constituents—the human beings in our constituency—we want the hospital to be saved.

If the A and E department goes, the hospital dies. That is an obvious reality. Everyone knows that. Every medical expert knows that. If the Minister could make extra concessions saying that closure would not take place by the target date, that further time would be given for consideration, and that the Government were not humiliated or embarrassed by having second thoughts on an unwise proposal, I could reconsider my position. From what has been said so far, I doubt whether that will happen, but this is the last opportunity for the Government to say, "Yes, we have listened not only to the people, but to our own Members of Parliament."

9.20 pm

Mr. David Congdon (Croydon, North-East)

This is our fourth debate on London's health in the past 13 months. That shows the level of interest in and concern about the future of health care in London.

One of the most depressing things about today's debate has been the unwillingness of Opposition Members to face up to the difficult challenges involved in taking decisions on health care in London. We have had a bit of a pretence that London is not over-resourced in terms of teaching hospitals and specialist facilities, but the facts stand for themselves. In 1993–94, average spending per capita in inner London was £565 per person compared with the national average of £370 per person. That shows that London is over-resourced.

In saying that, I recognise that today pressures exist on beds in London. That is why I have urged, and am pleased to urge again, caution on the pace of change in London. Many changes are occurring at the same time. We have care in the community and the internal market. All those issues must be taken into account.

In listening to the debate, especially in relation to Edgware general, Barnet, Bart's, St. Thomas's and Guy's hospitals, I am struck by the need for us to redefine what we mean by accident and emergency services. People who are injured in a major road accident, who suffer a severe stroke or cardiac arrest or who need intensive care, do not care which hospital an ambulance takes them to, so long as they receive first-class treatment. Frankly, they do not want to be taken to a third-rate A and E department where no consultant is on duty, where perhaps a junior has worked for only a few months, and where their chances of surviving are slight. We need to distinguish firmly between what I would define as major trauma centres and minor injuries departments.

My plea to my right hon. Friend the Secretary of State would be this: we need to be clear what we are talking about when discussing minor injuries departments. I should like them to be open 24 hours a day with a general practitioner on duty. It is rightly said that one of the problems in London is that the people of inner London use their hospital rather than their GP surgeries. That is partly because of poor primary care. We will not change that and, in a sense, I am not sure that it really matters, so long as those people receive the care they need. That is why local provision of minor injuries units could go a long way to allaying public concern about the closure of major A and E departments.

My only other main point, because I know that time is short tonight, relates to Bart's and the Royal London hospital. I have no axe to grind in relation to whether Bart's stays open or closes, but I have a concern, which I have expressed before, about the capital costs involved in relocating to the Royal London, which in gross terms amount to about £240 million. Given the comparatively small scale of the saving involved—£30 million a year—I am concerned about whether that represents good value for money, especially bearing in mind the fact that the dual-site option would achieve roughly half the savings at a small capital cost.

We all know the extent to which capital costs can be underestimated and revenue savings overestimated. I urge my right hon. Friend to ensure that the figures for Bart's and the Royal London are subjected to close scrutiny. As an outer London Member who for many years has been pressing for major capital investment at the local Mayday hospital, and who now knows the large sums that will be invested in the facilities at the Royal London, I must question whether that is the best value for money. We need rigorously to assess whether the single-site option is always better than the dual-site option.

I have no reservation in supporting the general direction of the changes proposed by my right hon. Friend the Secretary of State. She has taken courageous decisions, and she deserves our support.

9.25 pm

Mr. Nicholas Brown (Newcastle upon Tyne, East)

My hon. Friends the Members for Hampstead and Highgate (Ms Jackson) and for Newham, South (Mr. Spearing) echoed many of the speeches made during the debate when they asked the Government to think again. Whatever can be said for the Government's position as it has been represented tonight, it cannot possibly be said that it commands public support.

The petition to save Guy's hospital has been signed by more than 1 million people. Three mayors from three separate boroughs, one Labour, two Tory—at least, that was the roll call at the time—visited the Under-Secretary of State to discuss the Department's plans for the Edgware hospital. They represented 700,000 residents in north-west London. They were bluntly dismissed, told that the decision had already been made and that the time for negotiations had passed. The right hon. Member for Brent, North (Sir R. Boyson) expressed concern about that, as well he might. Some 183 local councillors have expressed their opinion on the Government's plan to close Edgware hospital. Only one has said that he supports the Government's position; the others do not.

Today, we have had the promise of a minor injuries unit at the earliest possible date. What sort of promise is that? Why was not it promised for the earliest possible date before today's debate? As my hon. Friend the Member for Barking (Ms Hodge) pointed out, such a promise is a con; it is nothing of any substance.

Some 1,244 people responded to the consultation on the Government's plans for Bart's—88 per cent. opposed the Government's plans. More than 1,000 people attended the health care crisis in London conference, which was organised by the National Health Service Support Federation last February. The conference unanimously adopted a resolution demanding an immediate halt to the shutdown of accident and emergency departments, to bed reductions and to hospital closures—a call that has been echoed by Labour Members throughout the debate.

The right hon. and learned Member for Putney (Mr. Mellor), no doubt unintentionally, made our point for us. While defending the broad thrust of Government policy, he also said that he has fought hard for local provision in his constituency. We can understand him saying that, so why cannot he allow his parliamentary colleagues the same right to fight for Edgware and the service that it provides to their constituents? My hon. Friend the Member for Thurrock (Mr. Mackinlay) pointed to the hypocrisy of some Conservative Members who support the thrust of Government policy, but defend provision in their own areas while not supporting other Members of Parliament, including Labour Members, who are trying to defend similar facilities in their constituencies.

Much has been said in the debate about political courage. My hon. Friend the Member for Leyton (Mr. Cohen) referred to the political courage of those Conservative Members who will not support the Government in the Lobby tonight. That takes courage, and I applaud them for that.

The political courage of the Secretary of State for Health has also been mentioned. I am all in favour of political courage, but not when it is providing the motivation to do the wrong thing. As has been said frequently in the debates which we have had on these topics, the Tomlinson report, on which the Government's decisions are founded, is fatally flawed. Tomlinson got it wrong. My hon. Friend the Member for Islington, North (Mr. Corbyn) said that the claim that London is over-bedded is inaccurate. London is not over-bedded. We are all grateful to Professor Jarman for the work that he has conducted which has shown that London is not over-bedded, but may well be under-bedded.

The hon. Member for Southend, East (Sir T. Taylor) talked about the over-provision of resources for London, but that is not true. It used to be believed, as the hon. Member for Southwark and Bermondsey (Mr. Hughes) pointed out, that London got 20 per cent. of the funding for only 15 per cent. of the population. However, the figures which the Department of Health publish include the costs for London allowance and for teaching facilities, and when allowance in the calculations is made for those additional costs, the funding and the population figures are broadly in line.

It was believed when Tomlinson reported that somehow primary care provision—I shall have more to say about this later—would reduce the demand for hospital services. It is my view that that is a false premise. By increasing the number of people who see a GP, the rate of diagnosis will be increased, and this will increase the number of referrals to London's hospitals.

Tomlinson believed that the location of casualty services was unimportant, but a number of lion Members—not least some Conservatives—have said that they do not accept that point of view. The closer a seriously injured person is to a casualty department, the more likely that he will be saved. Clinicians talk about the golden hour, which is vital. Certainly, a patient's chances are substantially diminished if the method of treating him is to put him on a helicopter and fly him up to Leeds. The right hon. Member for Brent, North (Sir R. Boyson) made that point rather well.

My hon. Friend the Member for Hampstead and Highgate (Ms Jackson) said that it was a mistake to assume that the two London regions can perform like an average English region. London is in many ways a special case. It has a large transient population, high levels of social deprivation and poverty, more mental illness, a lower than average provision for personal social services, and poor provision for the long-term care for the elderly. That puts extra pressure on accident and emergency units, and to some extent it is right to say that accident and emergency units are being used as a substitute for GP provision and good primary care.

My hon. Friend the Member for Hammersmith (Mr. Soley) made the point very well that Tomlinson misunderstood the relationship between inner and outer London. Tomlinson believed that patients from outer London do not make significant use of inner London hospitals. That is just wrong. Recent research carried out by the King's Fund shows that, of the 500,000 in-patients treated in inner London, 150,000 came from outer London and from other parts of the country. My hon. Friend the Member for Lewisham, West (Mr. Dowd) made reference to the service which Guy's hospital provides to his constituents.

When calculating the level of hospital provision in the capital, the Tomlinson report did not make a distinction between different types of hospital bed; it should have done. There is an important distinction between surgical beds, which are mostly used for elective cases, and medical beds, which are mostly used for emergency cases. The broad-brush proposal to close some 4,200 beds ignores the complexity of maintaining sufficient medical beds for urgent cases. If that were not understood at the time, we are informed every week of the outcome of that misunderstanding by the local press, who have yet another incident to draw to our attention.

The Tomlinson report referred several times to transitional funding. It was regarded as necessary to facilitate hospital closures and the development of primary and community services. The report did not cost those programmes and the Government provided no new money for them.

My hon. Friend the Member for Newham, North-East (Mr. Timms) spoke of a spiral of poor health and underachievement, and referred to the recent King's Fund report. That is of enormous importance for the whole country, but it has specific and special relevance to inner London, so it is right that we should look at primary care provision in London.

The Secretary of State is fond of quoting specialist experts—usually employed in her own Department—who support her point of view. Professor David London of the Royal College of Physicians said: London, like other big cities, needed a degree of rationalisation and that was always going to be painful. But it needed to be thought out. Money should have been put into it to ease the change, instead of being the cash-saving exercise it now appears to be. The hon. Member for Surbiton (Mr. Tracey) spoke about improvements in primary care. My hon. Friend the Member for Woolwich (Mr. Austin-Walker) made the sensible point that it is neither fair nor right to get rid of hospital beds before enhanced primary care provision is put in place.

Between 1984 and 1992, the number of general practitioners per head of the population increased by 10 per cent. in England, but that was not so in London. Over the same period in inner London, there was a 2 per cent. decrease and only a 2 per cent. increase in outer London. Yet, not surprisingly, London has the highest percentage of waiting lists of a year or more. The Secretary of State made much of the fact that the figures are coming down, but she should have said that London still has the highest figures and the lowest reduction in waiting lists from December 1994. London has fewer family health centres per thousand of population than Newcastle, Leeds, Birmingham, Liverpool, Manchester or Bristol. It thus has a specific primary care problem, which the Government have not yet resolved.

It is no secret that we hope to encourage Conservative Members to support us in the Lobby tonight. The House should be treated to some advice, which I hope it will respect because it was commissioned by the Government. It comes from the chief executives of the inner London health authorities whom the Government appointed. In their recent report, they say: 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. Yet assuredly, if our motion is defeated tonight, the system will have to cope with a further round of bed closures. They say: Some hospitals were found to be operating at 100 per cent. occupancy much of the time, and an average of 90–95 per cent. was common … generally speaking an average level of 85 per cent. occupancy is to be preferred. So the hospitals are working at capacity. They said: The overall conclusion is that London's acute hospitals are operating under very considerable pressure. I have not quoted those comments to make a party political point. We all have a duty to represent our constituents in this place and, as we consider how to vote tonight, we should consider those points, which come not from me but from the chief executives of the London health authorities. Every hon. Member would do well to bear them in mind.

Mr. Alan Lettin of the Royal College of Surgeons, speaking for health care professionals, says: Consultants feel the facilities are inadequate for the service we are expected to provide. We did warn the Government. The basis on which the cuts have been made was the King's Fund report, which has now been discredited. What consultants would say to the Government is: 'We never believed your figures because there are too many patients waiting for beds, emergencies and for routine surgery."' My hon. Friend the Member for Barking echoed that point.

If I am to encourage Conservative Members to support us in the Lobbies tonight, perhaps I should quote from someone whom I know that they all respect—the Secretary of State for Wales. In a speech on 4 April 1995, he said: I do not wish to see bed reductions while waiting lists are still quite long"— but waiting lists in London have just reached an all-time high of almost 180,000. He said: Make sure there are enough intensive care beds"— but recent tragedies in London and the south-east have shown that there are dangerously few intensive care beds.

One of the saddest aspects of the debate is to go, as I did recently, to Phillip Harris house to see the newly installed provision for intensive care beds. It was explained to me that all that provision is to be ripped out and smashed to pieces, even after it has been paid for, because the Government are no longer willing to provide the revenue funding. That is a shame. It is an act of vandalism, and should be resisted by the House.

The Secretary of State for Wales said: Make sure there are enough general medical and surgical beds. That is what our motion says, so I invite him, at least, to vote for it tonight.

The Secretary of State for Wales said: I suspect it is a myth that it is cheaper to close the older hospital and do everything in a new large one. My hon. Friend the Member for Hackney, South and Shoreditch (Mr. Sedgemore) made the same argument. He may not often be found on the same side as the Secretary of State for Wales, but he made the same argument when he said that the transfer of services from the Bart's site to the Royal London hospital is by no means a move that will save money, let alone do anything else.

The Save Guy's Campaign commissioned a report by independent consultants, which showed that a retention of an accident and emergency unit and in-patient services at Guy's was financially viable. Those arguments deserve consideration and, dare I say it, reconsideration.

The motion does not demand—as the Labour party would ideally like it to—reconsideration by an independent organisation. It asks only for reconsideration by the Secretary of State for Health. It asks her to think again.

The Secretary of State for Wales, who may be the next Secretary of State for Health, said: The local hospital remains a cherished institution. Of course, he was speaking for Wales, but he might have been speaking for Edgware as well. He said: I am asking the health authorities to slow down their passion for reorganising. It must go at a pace people accept. He is certainly not the only Conservative Member of Parliament to have said that recently. He also said, referring to reorganisation: It must be based on health arguments, not financial considerations. The hon. Member for Hendon, North (Sir J. Gorst) said: human beings, not balance sheets, come first. That remark found a cheer from the Opposition, at least.

I urge the House to listen carefully to what was said tonight by Conservative Members as well as Labour Members, worried for their constituents. This is the last chance for health provision in London. The Opposition's motion deserves the support of the whole House in the Division tonight.

9.42 pm

The Minister for Health (Mr. Gerald Malone)

Never has there been a more unlikely suitor of Conservative Members than the hon. Member for Newcastle upon Tyne, East (Mr. Brown). It was an astonishing performance, in which he admitted that he had not even been able to table the motion that he wanted to. I wonder who stopped him. Is it yet another story of a split between the hon. Gentleman and the right hon. Member for Derby, South (Mrs. Beckett)? Mr. Nicholas Brown: It is self-restraint.

Mr. Malone

Doubtless, when he takes over, we shall see the end of all that, shall we not?

Mr. David Hinchliffe (Wakefield)

When my hon. Friend takes over?

Mr. Malone

From his right hon. Friend the Member for Derby, South.

I thought that in this, the fourth debate about health in London in which I have spoken as Minister of State, we might have heard something positive from the right hon. Member for Derby, South or from the hon. Member for Newcastle upon Tyne, East. However, I agreed entirely with my right hon. and learned Friend the Member for Putney (Mr. Mellor) when he said that there was no policy; that we had heard nothing in the debate about what the Labour party would do. On four successive occasions, health in London has been debated and we have heard nothing positive. That point was reiterated by my hon. Friend the Member for Croydon, North-East (Mr. Congdon).

Today's debate gave the Opposition the opportunity to fill in the blank pages of their policy. They could have told the House what they would do about London's health service. They could have told it, and Londoners, about their plans to improve primary care and prepare hospitals in London for the 21st century. We heard nothing about that. The Opposition could have made commitments to validate their charge, perhaps, that the Government have got it wrong.

With any charge from any responsible Opposition that the Government have got it wrong comes an important corollary: they must have an argument about what they would do to put it right. I thought that if we did not hear it from the right hon. Member for Derby, South, we might hear it from her hon. Friend the Member for Newcastle upon Tyne, East, but we heard nothing.

Let me sum up the Government's case briefly. It is in three parts. First, clinical excellence is very important for London's hospitals. That means bringing specialist services together. It means, of course, that some hospitals have to change and, indeed, that some have to close. There was consensus on that under the reign of the right hon. Lady's predecessor, but that seems to have disappeared. Other hospitals—for example, Edgware, which has been quite rightly mentioned frequently in the debate—will have to change in character to community hospitals, delivering care closer to patients than they were able to do before. That change is in the interests of the community.

It is extremely important to meet the challenges of technological change, as well as those associated with increasing day care, earlier discharge and the falling number of referrals from outside London—not just from outer London to inner London hospitals, but from the home counties and the rest of the country.

Mr. David Wilshire (Spelthorne)

Has my hon. Friend had the chance to study the letter that I sent to him from my health authority? It explained that the rapidly accelerating switch to treating people locally meant that, last year, North West Surrey health authority had to encourage my local GPs and local consultants to persuade their patients to go to central London rather than be treated locally, to use up contract money. I must tell my hon. Friend that my constituents want to be treated locally, not bundled off to central London to help to keep other hospitals viable.

Mr. Malone

I have read the letter that my hon. Friend sent me. He made a valid point, which will be echoed by many hon. Members.

It is important that London meets the challenge of changing referrals. It is essential to ensure that funds that are allocated to health authorities in London go on patient care and are not swallowed by high-cost institutions.

The investment that the Government have made in primary care for London—£210 million in recent years—is second to none and is transforming the face of primary care in the city and bringing new facilities on stream on a day-to-day basis.

The hon. Member for Southwark and Bermondsey (Mr. Hughes) asked the fundamental question: is London being overfunded? If he looks at the weighted capitation basis of funding, he will see that it is overresourced by £91 million. That does not take into account top-sliced funding that goes towards transitional payments to maintain institutions. That overfunding is not the main argument, because the hon. Gentleman and other hon. Members who clearly have constituency interests in the city should ask themselves whether they want to see the resources that are given to their health authorities, which are meant to be spent on patient care, absorbed by institutions that are not run on an efficient basis. I suggest that, in their constituency interests, that should not be so.

My right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke) asked specifically about consideration of the York report. I can tell him that it was given proper consideration. The Treasury has scrutinised the business case and it said that the case for a single-site solution seems robust and well founded in contrast to what was put forward.

My right hon. and learned Friend the Member for Putney made a number of valid points about the difficulty of the detail. I agree that the detail is difficult. That is what the Opposition find difficult to understand. Until now, they have all gone with the policy for change and argued that change is essential, but when we get down to the agenda of change, they disappear over the horizon without an idea to bring to bear on the argument.

My right hon. and learned Friend the Member for Putney asked about the role of the purchasing authority with regard to the hospital in his constituency. The health authority is still to be persuaded about that case, but I have no doubt that my right hon. and learned Friend will follow up the representations that he has already made to me, and that he will continue to press the authority very firmly about that matter.

My right hon. Friend the Member for Chelsea (Sir N. Scott) raised an important point about the Royal Brompton hospital. My Department and the Royal Brompton are currently looking at various development possibilities and I know that my right hon. Friend continues to make strong representations on the hospital's behalf. My hon. Friend the Member for Surbiton (Mr. Tracey) emphasised the technological advances that have been made in health care. It is important that we recognise technology changes and build hospitals for the 21st century; we must not be left behind.

I now come to the comments of my right hon. Friend the Member for Brent, North (Sir R. Boyson) and my hon. Friends the Members for Hendon, North (Sir J. Gorst) and for Harrow, East (Mr. Dykes). They have clear constituency concerns, and I must admit quite frankly that I cannot meet all the points that they raised. However, I ask them to bear in mind the fact that Edgware hospital will not close, as has been suggested in the popular press. I know that they recognise that fact.

Edgware hospital will remain as a community hospital that will deliver patient care to the community. It will provide a minor accident treatment service, which will cater for approximately 50 per cent. of those who use the current accident and emergency service. Some £60 million will be invested in the hospital in Brent in order to turn it into a first-class facility.

Sir John Gorst

So that I may be absolutely certain that I will enter the correct Division Lobby this evening, I ask my hon. Friend to leave aside the palliatives, sedatives and tranquillisers that have been dressed up as concessions and, even at this 11th hour, to give an undertaking that the accident and emergency department at Edgware hospital will remain open.

Mr. Malone

I cannot give that undertaking, because it would be the wrong thing to do. The Government will put in place new, worthwhile facilities, and I hope that hon. Members in the area will be able to reassure their constituents about service provision. If my hon. Friend were to visit some minor units that have been established already—for example, the St. Charles's hospital minor injuries unit that was referred to in the debate—he would find that they are first-class facilities that could meet the needs of his constituents extremely well. [Interruption.] I hear an intervention from a sedentary position that no one believes me. I do not ask Labour Members to believe what I say; they should go and see for themselves what those units, which are close to the community, can provide. They are excellently run and they have zero waiting times. They are first-class facilities.

Mr. Dykes

Even if the Minister cannot give that concession to my hon. Friend the Member for Hendon, North (Sir J. Gorst), can he not at least postpone the closure of the A and E unit at Edgware hospital and confirm that there will be additional ambulance provision pending further examination of the whole question?

Mr. Malone

My hon. Friend knows about the additional ambulance provision that has been promised already. I cannot promise any further delay or postponement of the closure of the A and E unit at Edgware hospital. However, I emphasise the pledge that my right hon. Friend the Secretary of State has given, that we will put in place equivalent, if not better, facilities that will soon be up and running. That is not merely a pledge from Ministers or from the health authorities; buildings of bricks and mortar will be occupied by doctors and nurses who will run the facilities in a proper way. I hope that my hon. Friend will accept my assurance.

I come to the remarks of my hon. Friend the Member for Broxbourne (Mrs. Roe), who is Chairman of the Select Committee on Health. She referred to the way in which the Committee scrutinises the Government's policies. That scrutiny is very welcome and I know that my right hon. Friend, fresh from this debate, is looking forward to appearing before the Select Committee tomorrow.

The hon. Member for Islington, North (Mr. Corbyn) talked about London waiting figures. May I say to the whole House that there has been a tremendous achievement on waiting figures in London? In the 12 months up to March 1995, the number of people who had been waiting for more than one year fell by 26.3 per cent. That is an enormous achievement. I do not know why Opposition Members who claim to support the health service denigrate it when it makes such achievements, and try to cast it down.

I tell the hon. Member for Newcastle upon Tyne, East that the health service in London is not as good as in other parts of the country because we have got to get London's health service into the same shape as the health service in other parts of the country. It is the Opposition motion that stands exactly in the way of that.

The hon. Member for Newham, South (Mr. Spearing) made an interesting speech. He gave a historical analysis of what has happened in health, with which I do not quite agree. He harked back to the good old days before 1990, when he said that there was a consensus on health policy. I remember being in the House between 1983 and 1987. To echo the words of my right hon. Friend the Member for Sutton Coldfield (Sir N. Fowler), if that was consensus before 1990, God help us if war had broken out, because the truth is that the Opposition have attempted to thwart every attempt made by the Government since 1979 to reform the health service and make it more efficient.

The hon. Member for Woolwich (Mr. Austin-Walker) talked about resources and said that we would have to be extremely careful not to take away care provision before we had provided other facilities. That is right, and it was one of the pledges that my right hon. Friend the Secretary of State gave the House; I am pleased to reiterate it in my winding-up speech.

My hon. Friend the Member for Hendon, South (Mr. Marshall) welcomed the primary care initiative. [Interruption.]

Madam Speaker

Order. The House should settle down and hear the last minutes of the Minister's winding-up speech. The House is much too noisy. Too many meetings are taking place.

Mr. Malone

I am glad that my hon. Friend the Member for Hendon, South welcomed that initiative. I assure him that the pledge to continue to improve the London ambulance service will be honoured.

The right hon. Member for Derby, South made much in her remarks about the NHS building programme. I have to tell her, on behalf of my right hon. Friend the Secretary of State, that my right hon. Friend stated that there had been one new building programme a week in the five years to March 1994. I have to apologise on behalf of my right hon. Friend, because she misled the House. That would have led to a total of 260 building programmes over that period. There were, in fact, 375 building schemes, each costing over a million pounds, completed in an NHS programme worth over £1 billion nationally. Since 1979, the Government have put £22.5 billion into NHS building programmes.

What we get from the Opposition is impresario politics. Today, as the right hon. Member for Derby, South was speaking, we saw that the soundbites were taken by the Leader of the Opposition as he appeared in Bart's hospital. I have a question that everybody in Bart's hospital would like to ask the Opposition. If they take the political credit for appearing to save Bart's hospital, are they prepared to stand up at the Dispatch Box today, tonight, at this moment, and say that they would save Bart's hospital?

Mr. Nicholas Brown

The Minister will find out in the Lobby in three minutes' time.

Mr. Malone

The hon. Gentleman gave no policy commitment or anything of that sort. There never has been from the Labour party.

At the core of this debate is the point about hospitals. There is a tendency in some quarters to defend the very small hospital on the ground of its localism and intimacy … but everybody knows today that if a hospital is to be efficient it must provide a number of specialised services. Although I am not myself a devotee of bigness for bigness sake, I would rather be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy in a small one."—[Official Report, 30 April 1946; Vol. 422, c. 44.] I wonder whether the Opposition agree with that. They probably do not. That is from the speech of Aneurin Bevan in moving the Second Reading of the National Health Service Bill on 30 April 1946. The Opposition have resiled from what was promised then. They have no policies. Bevan took on the challenges, which the Opposition are not prepared to do. That is why the House should reject the Opposition's motion.

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

The House divided: Ayes 308, Noes 320.

Division No. 144]	[9.59 pm
AYES
Abbott, Ms Diane	Blunkett, David
Adams, Mrs Irene	Boateng, Paul
Anger, Nick	Boyes, Roland
Ainsworth, Robert (Coventry NE)	Bradley, Keith
Allen, Graham	Bray, Dr Jeremy
Alton, David	Brooke, Rt Hon Peter
Anderson, Donald (Swansea E)	Brown, Gordon (Dunfermline E)
Anderson, Ms Janet (Ros'dale)	Brown, N (N'c'tle upon Tyne E)
Armstrong, Hilary	Bruce, Malcolm (Gordon)
Ashdown, Rt Hon Paddy	Burden, Richard
Ashton, Joe	Byers, Stephen
Austin-Walker, John	Caborn, Richard
Banks, Tony (Newham NM)	Callaghan, Jim
Barnes, Harry	Campbell, Mrs Anne (C'bridge)
Barron, Kevin	Campbell, Menzies (Fife NE)
Battle, John	Campbell, Ronnie (Blyth V)
Bayley, Hugh	Campbell-Savours, D N
Beckett, Rt Hon Margaret	Canavan, Dennis
Beith, Rt Hon A J	Cann, Jamie
Bell, Stuart	Carlile, Alexander (Montgomery)
Benn, Rt Hon Tony	Chidgey, David
Bennett, Andrew F	Chisholm, Malcolm
Benton, Joe	Church, Judith
Bermingham, Gerald	Clapham, Michael
Berry, Roger	Clark, Dr David (South Shields)
Betts, Clive	Clarke, Eric (Midlothian)
Blair, Rt Hon Tony	Clarke, Tom (Monklands W)

Clelland, David	Hinchliffe, David
Clwyd, Mrs Ann	Hodge, Margaret
Coffey, Ann	Hoey, Kate
Cohen, Harry	Hogg, Norman (Cumbernauld)
Connarty, Michael	Home Robertson, John
Cook, Frank (Stockton N)	Hood, Jimmy
Cook, Robin (Livingston)	Hoon, Geoffrey
Corbett Robin	Howarth, George (Knowsley North)
Corbyn, Jeremy	Howells, Dr. Kim (Pontypridd)
Corston, Jean	Hoyle, Doug
Cousins, Jim	Hughes, Kevin (Doncaster N)
Cox, Tom	Hughes, Robert (Aberdeen N)
Cummings, John	Hughes, Roy (Newport E)
Cunliffe, Lawrence	Hughes, Simon (Southwark)
Cunningham, Jim (Covy SE)	Hume, John
Cunningham, Rt Hon Dr John	Hutton,John
Dafis, Cynog	Illsley, Eric
Dalyell, Tam	Ingram, Adam
Darling, Alistair	Jackson, Glenda (H'stead)
Davidson, Ian	Jackson, Helen (Shef'ld, H)
Davies, Bryan (Oldham C'tral)	Jamieson, David
Davies, Rt Hon Denzil (Llanelli)	Janner, Greville
Davies, Ron (Caerphilly)	Johnston, Sir Russell
Davis, Terry (B'ham, H'dge H'l)	Jones, Barry (Alyn and D'side)
Denham, John	Jones, leuan Wyn (Ynys Môn)
Dewar, Donald	Jones, Jon Owen (Cardiff C)
Dixon, Don	Jones, Lynne (B'ham S O)
Dobson, Frank	Jones, Martyn (Clwyd, SW)
Donohoe, Brian H	Jones, Nigel (Cheltenham)
Dunnachie, Jimmy	Jowell, Tessa
Dunwoody, Mrs Gwyneth	Kaufman, Rt Hon Gerald
Eagle, Ms Angela	Keen, Alan
Eastham, Ken	Kennedy, Charles (Ross,C&S)
Enright, Derek	Kennedy, Jane (Lpool Brdgn)
Etherington, Bill	Khabra, Piara S
Evans, John (St Helens N)	Kilfoyle, Peter
Ewing, Mrs Margaret	Kirkwood, Archy
Fatchett Derek	Lestor, Joan (Eccles)
Faulds, Andrew	Lewis, Terry
Field, Frank (Birkenhead)	Litherland, Robert
Fisher, Mark	Livingstone, Ken
Flynn, Paul	Lloyd, Tony (Stretford)
Foster, Rt Hon Derek	Llwyd, Elfyn
Foster, Don (Bath)	Loyden, Eddie
Foulkes, George	Lynne, Ms Liz
Fraser, John	McAllion, John
Fyfe, Maria	McAvoy, Thomas
Galbraith, Sam	McCartney, Ian
Galloway, George	McCrea, The Reverend William
Gapes, Mike	Macdonald, Calum
Garrett, John	McFall, John
George, Bruce	McKelvey, William
Gerrard, Neil	Mackinlay, Andrew
Gilbert, Rt Hon Dr John	McLeish, Henry
Godman, Dr Norman A	Maclennan, Robert
Godsiff, Roger	McMaster, Gordon
Golding, Mrs Llin	McNamara, Kevin
Gordon, Mildred	MacShane, Denis
Gorst Sir John	McWilliam, John
Graham, Thomas	Madden, Max
Grant, Bernie (Tottenham)	Maddock, Diana
Griffiths, Nigel (Edinburgh S)	Mahon, Alice
Griffiths, Win (Bridgend)	Mallon, Seamus
Grocott, Bruce	Mandelson, Peter
Gunnell, John	Marek, Dr John
Hain, Peter	Marshall, David (Shettleston)
Hal, Mike	Marshall, Jim (Leicester, S)
Hanson, David	Martin, Michael J (Springburn)
Hardy, Peter	Martlew, Eric
Harman, Ms Harriet	Maxton, John
Harvey, Nick	Meacher, Michael
Hattersley, Rt Hon Roy	Meale, Alan
Henderson, Doug	Michael, Alun
Hendron, Dr Joe	Michie, Bill (Sheffield Heeley)
Heppell, John	Michie, Mrs Ray (Argyll & Bute)
Hill, Keith (Streatham)	Milburn, Alan

Miller, Andrew	Shore, Rt Hon Peter
Mitchell, Austin (Gt Grimsby)	Short, Clare
Moonie, Dr Lewis	Simpson, Alan
Morgan, Rhodri	Skinner, Dennis
Morley, Elliot	Smith, Andrew (Oxford E)
Morris, Rt Hon Alfred (Wy'nshawe)	Smith, Chris (Isl'ton S & Fsbury)
Morris, Estelle (B'ham Yardley)	Smith, Llew (Blaenau Gwent)
Morris, Rt Hon John (Aberavon)	Smyth, The Reverend Martin (Belfast S)
Mowlam, Marjorie
Mudie, George	Snape, Peter
Mullin, Chris	Soley, Clive
Murphy, Paul	Spearing, Nigel
Oakes, Rt Hon Gordon	Spellar, John
O'Brien, Mike (N W'kshire)	Squire, Rachel (Dunfermline W)
O'Brien, William (Normanton)	Steel, Rt Hon Sir David
O'Hara, Edward	Steinberg, Gerry
Olner, Bill	Stevenson, George
O'Neill, Martin	Stott, Roger
Orme, Rt Hon Stanley	Strang, Dr. Gavin
Parry, Robert	Straw, Jack
Patchett, Terry	Sutcliffe, Gerry
Pearson Ian	Taylor, Mrs Ann (Dewsbury)
Pendry, Tom	Taylor, Rt Hon John D (Strgfd)
Pickthall, Colin	Taylor, Matthew (Truro)
Pike, Peter L	Thompson, Jack (Wansbeck)
Pope, Greg	Timms, Stephen
Powell, Ray (Ogmore)	Tipping, Paddy
	Touhig, Don
Prentice, Bridget (Lew'm E)	Trimble David
Prentice, Gordon (Pendle)	Turner, Dennis
Prescott, Rt Hon John	Tyler, Paul
Primarolo, Dawn	Vaz, Keith
Purchase, Ken	Walker, Rt Hon Sir Harold
Quin, Ms Joyce	Wallace, James
Radice, Giles	Walley, Joan
Randall, Stuart	Wardell, Gareth (Gower)
Raynsford, Nick	Wareing, Robert N
Redmond, Martin	Watson, Mike
Reid, Dr John	Welsh, Andrew
Rendel, David	Wicks, Malcolm
Robertson, George (Hamilton)	Wigley, Dafydd
Robinson, Geoffrey (Co'try NW)	Williams, Rt Hon Alan (SW'n W)
Robinson, Peter (Belfast E)	Williams, Alan W (Carmarthen)
Rogers, Allan	Wilson, Brian
Rooker, Jeff	Winnick, David
Rooney, Terry	Wise, Audrey
Ross, Ernie (Dundee W)	Worthington, Tony
Ross, William (E Londonderry)	Wray, Jimmy
Rowlands, Ted	Wright, Dr Tony
Ruddock, Joan	Young, David (Bolton SE)
Salmond, Alex
Sedgemore, Brian	Tellers for the Ayes:
Sheerman, Barry	Mrs. Barbara Roche and
Sheldon, Rt Hon Robert	Mr. Jim Dowd.
NOES
Ainsworth, Peter (East Surrey)	Batiste, Spencer
Aitken, Rt Hon Jonathan	Bellingham, Henry
Alexander, Richard	Bendall, Vivian
Alison, Rt Hon Michael (Selby)	Beresford, Sir Paul
Allason, Rupert (Torbay)	Biffen, Rt Hon John
Amess, David	Body, Sir Richard
Ancram, Michael	Bonsor, Sir Nicholas
Arbuthnot, James	Booth, Hartley
Arnold, Jacques (Gravesham)	Boswell, Tim
Arnold, Sir Thomas (Hazel Grv)	Bottomley, Peter (Eltham)
Ashby, David	Bottomley, Rt Hon Virginia
Atkins, Robert	Bowden, Sir Andrew
Atkinson, David (Bour'mouth E)	Bowis, John
Atkinson, Peter (Hexham)	Brandreth, Gyles
Baker, Rt Hon Kenneth (Mole V)	Brazier, Julian
Baker, Nicholas (North Dorset)	Bright, Sir Graham
Baldry, Tony	Brown, M (Brigg & Cl'thorpes)
Banks, Matthew (Southport)	Browning, Mrs Angela
Banks, Robert (Harrogate)	Bruce, Ian (Dorset)
Bates, Michael	Budgen, Nicholas

Burns, Simon	Greenway, John (Ryedale)
Burt, Alistair	Griffiths, Peter (Portsmouth, N)
Butcher, John	Grylls, Sir Michael
Butler, Peter	Gummer, Rt Hon John Selwyn
Butterfill, John	Hague, William
Carlisle, John (Luton North)	Hamilton, Rt Hon Sir Archibald
Carlisle, Sir Kenneth (Lincoln)	Hamilton, Neil (Tatton)
Carrington, Matthew	Hampson, Dr Keith
Carttiss, Michael	Hanley, Rt Hon Jeremy
Cash, William	Hannam, Sir John
Channon, Rt Hon Paul	Hargreaves, Andrew
Churchill, Mr	Harris, David
Clappison, James	Haselhurst, Alan
Clark, Dr Michael (Rochford)	Hawkins, Nick
Clarke, Rt Hon Kenneth (Ru'clif)	Hawksley, Warren
Clifton-Brown, Geoffrey	Hayes, Jerry
Coe, Sebastian	Heald, Oliver
Colvin, Michael	Heath, Rt Hon Sir Edward
Congdon, David	Heathcoat-Amory, David
Conway, Derek	Hendry, Charles
Coombs, Anthony (Wyre For'st)	Heseltine, Rt Hon Michael
Coombs, Simon (Swinton)	Hicks, Robert
Cope, Rt Hon Sir John	Higgins, Rt Hon Sir Terence
Cormack, Sir Patrick	Hill, James (Southampton Test)
Couchman, James	Hogg, Rt Hon Douglas (G'tham)
Cran, James	Horam, John
Critchley, Julian	Hordern, Rt Hon Sir Peter
Currie, Mrs Edwina (S D'by'ire)	Howard, Rt Hon Michael
Curry, David (Skipton & Ripon)	Howarth, Alan (Strat'rd-on-A)
Davies, Quentin (Stamford)	Howell, Rt Hon David (G'dford)
Davis, David (Boothferry)	Howell, Sir Ralph (N Norfolk)
Day, Stephen	Hughes, Robert G (Harrow W)
Deva, Nirj Joseph	Hunt, Rt Hon David (Wirral W)
Delvin, Tim	Hunt, Sir John (Ravensboume)
Dicks, Terry	Hunter, Andrew
Dorrell, Rt Hon Stephen	Hurd, Rt Hon Douglas
Douglas-Hamilton, Lord James	Jack, Michael
Dover, Den	Jackson, Robert (Wantage)
Duncan, Alan	Jenkin, Bernard
Duncan Smith, Iain	Jessel, Toby
Dunn, Bob	Johnson Smith, Sir Geoffrey
Durant, Sir Anthony	Jones, Gwilym (Cardiff N)
Eggar, Rt Hon Tim	Jones, Robert B (W Hertfdshr)
Elletson, Harold	Jopling, Rt Hon Michael
Emery, Rt Hon Sir Peter	Kellett-Bowman, Dame Elaine
Evans, David (Welwyn Hatfield)	Key, Robert
Evans, Jonathan (Brecon)	King, Rt Hon Tom
Evans, Nigel (Ribble Valley)	Kirkhope, Timothy
Evans, Roger (Monmouth)	Knapman, Roger
Evennett, David	Knight, Mrs Angela (Erewash)
Faber, David	Knight, Greg (Derby N)
Fabricant, Michael	Knight, Dame Jill (Bir'm E'st'n)
Fenner, Dame Peggy	Knox, Sir David
Field, Barry (Isle of Wight)	Kynoch, George (Kincardine)
Fishburn, Dudley	Lait, Mrs Jacqui
Forman, Nigel	Lamont, Rt Hon Norman
Forsyth, Rt Hon Michael (Stirling)	Lang, Rt Hon Ian
Forth, Eric	Lawrence, Sir Ivan
Fowler, Rt Hon Sir Norman	Legg, Barry
Fox, Dr Liam (Woodspring)	Leigh, Edward
Fox, Sir Marcus (Shipley)	Lennox-Boyd, Sir Mark
Freeman, Rt Hon Roger	Lester, Jim (Broxtowe)
French, Douglas	Lidington, David
Fry, Sir Peter	Lilley, Rt Hon Peter
Gale, Roger	Lloyd, Rt Hon Sir Peter (Fareham)
Gallie, Phil	Lord, Michael
Gardiner, Sir George	Luff, Peter
Garel-Jones, Rt Hon Tristan	Lyell, Rt Hon Sir Nicholas
Garnier, Edward	MacGregor, Rt Hon John
Gill, Christopher	MacKay, Andrew
Gillan, Cheryl	Maclean, David
Goodlad, Rt Hon Alastair	McLoughlin, Patrick
Goodson-Wickes, Dr Charles	McNair-Wilson, Sir Patrick
Gorman, Mrs Teresa	Madel, Sir David
Grant, Sir A (SW Cambs)	Maitland, Lady Olga
Greenway, Harry (Ealing N)	Major, Rt Hon John

Malone, Gerald	Skeet, Sir Trevor
Mans, Keith	Smith, Sir Dudley (Warwick)
Marland, Paul	Smith, Tim (Beaconsfield)
Marlow, Tony	Soames, Nicholas
Marshall, John (Hendon S)	Speed, Sir Keith
Marshall, Sir Michael (Arundel)	Spencer, Sir Derek
Martin, David (Portsmouth S)	Spicer, Sir James (W Dorset)
Mates, Michael	Spicer, Michael (S Worcs)
Mawhinney, Rt Hon Dr Brian	Spink, Dr Robert
Mayhew, Rt Hon Sir Patrick	Spring, Richard
Mellor, Rt Hon David	Sproat, Iain
Merchant Piers	Squire, Robin (Hornchurch)
Mills, Iain	Stanley, Rt Hon Sir John
Mitchell, Andrew (Gedling)	Steen, Anthony
Mitchell, Sir David (NW Hants)	Stephen, Michael
Moate, Sir Roger	Stern, Michael
Monro, Sir Hector	Stewart, Allan
Montgomery, Sir Fergus	Streeter, Gary
Moss, Malcolm	Sumberg, David
Needham, Rt Hon Richard	Sweeney, Walter
Nelson, Anthony	Sykes, John
Neubert, Sir Michael	Tapsell, Sir Peter
Newton, Rt Hon Tony	Taylor, Ian (Esher)
Nicholls, Patrick	Taylor, John M (Solihull)
Nicholson, David (Taunton)	Taylor, Sir Teddy (Southend, E)
Nicholson, Emma (Devon West)	Temple-Morris, Peter
Norris, Steve	Thomason, Roy
Onslow, Rt Hon Sir Cranley	Thompson, Sir Donald (C'er V)
Oppenheim, Phillip	Thompson, Patrick (Norwich N)
Ottaway, Richard	Thornton, Sir Malcolm
Page, Richard	Thurnham, Peter
Paice, James	Townend, John (Bridlington)
Patrick, Sir Irvine	Townsend, Cyril D (Bexl'yh'th)
Patten, Rt Hon John	Tracey, Richard
Pattie, Rt Hon Sir Geoffrey	Trend, Michael
Pawsey, James	Trotter, Neville
Peacock, Mrs Elizabeth	Twinn, Dr Ian
Pickles, Eric	Vaughan, Sir Gerard
Porter, Barry (Wirral S)	Viggers, Peter
Porter, David (Waveney)	Waldegrave, Rt Hon William
Portillo, Rt Hon Michael	Walden, George
Powell, William (Corby)	Walker, Bill (N Tayside)
Rathbone, Tim	Waller, Gary
Redwood, Rt Hon John	Ward, John
Renton, Rt Hon Tim	Wardle, Charles (Bexhill)
Richards, Rod	Waterson, Nigel
Riddick, Graham	Watts, John
Rifkind, Rt Hon Malcolm	Wells, Bowen
Robathan, Andrew	Wheeler, Rt Hon Sir John
Roberts, Rt Hon Sir Wyn	Whitney, Ray
Robertson, Raymond (Ab'd'n S)	Whittingdale, John
Robinson, Mark (Somerton)	Widdecombe, Ann
Roe, Mrs Marion (Broxbourne)	Wiggin, Sir Jerry
Rowe, Andrew (Mid Kent)	Wilkinson, John
Rumbold, Rt Hon Dame Angela	Willetts, David
Ryder, Rt Hon Richard	Wilshire, David
Sackville, Tom	Winterton, Mrs Ann (Congleton)
Sainsbury, Rt Hon Sir Timothy	Winterton, Nicholas (Macc'fld)
Scott, Rt Hon Sir Nicholas	Wolfson, Mark
Shaw, David (Dover)	Wood, Timothy
Shaw, Sir Giles (Pudsey)	Yeo, Tim
Shephard, Rt Hon Gillian	Young, Rt Hon Sir George
Shepherd, Colin (Hereford)
Shepherd, Richard (Aldridge)	Tellers for the Noes:
Shersby, Michael	Mr. David Lightbown and
Sims, Roger	Mr. Sydney Chapman.

Question accordingly negatived.

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

The House divided: Ayes 319, Noes 302.

Division No. 145]	[10.17 pm
AYES
Ainsworth, Peter (East Surrey)	Devlin, Tim
Aitken, Rt Hon Jonathan	Dicks, Terry
Alexander, Richard	Dorrell, Rt Hon Stephen
Alison, Rt Hon Michael (Selby)	Douglas-Hamilton, Lord James
Allason, Rupert (Torbay)	Dover, Den
Amess, David	Duncan, Alan
Ancram, Michael	Duncan-Smith, Iain
Arbuthnot, James	Dunn, Bob
Arnold, Jacques (Gravesham)	Durant, Sir Anthony
Arnold, Sir Thomas (Hazel Grv)	Eggar, Rt Hon Tim
Ashby, David	Elletson, Harold
Atkins, Robert	Emery, Rt Hon Sir Peter
Atkinson, David (Bour'mouth E)	Evans, David (Welwyn Hatfield)
Atkinson, Peter (Hexham)	Evans, Jonathan (Brecon)
Baker, Rt Hon Kenneth (Mole V)	Evans, Nigel (Ribble Valley)
Baker, Nicholas (North Dorset)	Evans, Roger (Monmouth)
Baldry, Tony	Evennett, David
Banks, Matthew (Southport)	Faber, David
Banks, Robert (Harrogate)	Fabricant, Michael
Bates, Michael	Fenner, Dame Peggy
Batiste, Spencer	Field, Barry (Isle of Wight)
Bellingham, Henry	Fishburn, Dudley
Bendall, Vivian	Forman, Nigel
Beresford, Sir Paul	Forsyth, Rt Hon Michael (Stirling)
Biffen, Rt Hon John	Forth, Eric
Body, Sir Richard	Fowler, Rt Hon Sir Norman
Bonsor, Sir Nicholas	Fox, Sir Marcus (Shipley)
Booth, Hartley	Freeman, Rt Hon Roger
Boswell, Tim	French, Douglas
Bottomley, Peter (Eltham)	Fry, Sir Peter
Bottomley, Rt Hon Virginia	Gale, Roger
Bowden, Sir Andrew	Gallie, Phil
Bowis, John	Gardiner, Sir George
Brandreth, Gyles	Garel-Jones, Rt Hon Tristan
Brazier, Julian	Garnier, Edward
Bright, Sir Graham	Gill, Christopher
Brown, M (Brigg & Cl'thorpes)	Gillan, Cheryl
Browning, Mrs Angela	Goodlad, Rt Hon Alastair
Bruce, Ian (Dorset)	Goodson-Wickes, Dr Charles
Budgen, Nicholas	Gorman, Mrs Teresa
Burns, Simon	Grant, Sir A (SW Cambs)
Burt, Alistair	Greenway, Harry (Ealing N)
Butcher, John	Greenway, John (Ryedale)
Butler, Peter	Griffiths, Peter (Portsmouth, N)
Butterfill, John	Grylls, Sir Michael
Carlisle, John (Luton North)	Gummer, Rt Hon John Selwyn
Carlisle, Sir Kenneth (Lincoln)	Hague, William
Carrington, Matthew	Hamilton, Rt Hon Sir Archibald
Carttiss, Michael	Hamilton, Neil (Tatton)
Cash, William	Hampson, Dr Keith
Channon, Rt Hon Paul	Hanley, Rt Hon Jeremy
Churchill, Mr	Hannam, Sir John
Clappison, James	Hargreaves, Andrew
Clark, Dr Michael (Rochford)	Harris, David
Clarke, Rt Hon Kenneth (Ru'clif)	Haselhurst, Alan
Clifton-Brown, Geoffrey	Hawkins, Nick
Coe, Sebastian	Hawksley, Warren
Colvin, Michael	Hayes, Jerry
Congdon, David	Heald, Oliver
Conway, Derek	Heath, Rt Hon Sir Edward
Coombs, Anthony (Wyre For'st)	Heathcoat-Amory, David
Coombs, Simon (Swindon)	Hendry, Charles
Cope, Rt Hon Sir John	Heseltine, Rt Hon Michael
Cormack, Sir Patrick	Hicks, Robert
Couchman, James	Higgins, Rt Hon Sir Terence
Cran, James	Hill, James (Southampton Test)
Critchley, Julian	Hogg, Rt Hon Douglas (G'tham)
Currie, Mrs Edwina (S D'by'ire)	Horam, John
Curry, David (Skipton & Ripon)	Hordern, Rt Hon Sir Peter
Davies, Quentn (Stamford)	Howard, Rt Hon Michael
Davis, David (Boothferry)	Howarth, Alan (Strat'rd-on-A)
Day, Stephen	Howell, Rt Hon David (G'dford)
Deva, Nirj Joseph	Howell, Sir Ralph (N Norfolk)

Hughes, Robert G (Harrow W)	Page, Richard
Hunt, Rt Hon David (Wirral W)	Paice, James
Hunt, Sir John (Ravensbourne)	Patnick, Sir Irvine
Hunter, Andrew	Patten, Rt Hon John
Hurd, Rt Hon Douglas	Pattie, Rt Hon Sir Geoffrey
Jack, Michael	Pawsey, James
Jackson, Robert (Wantage)	Peacock, Mrs Elizabeth
Jenkin, Bernard	Pickles, Eric
Jessel, Toby	Porter, Barry (Wirral S)
Johnson Smith, Sir Geoffrey	Porter, David (Waveney)
Jones, Gwilym (Cardiff N)	Portillo, Rt Hon Michael
Jones, Robert B (W Hertfdshr)	Powell, William (Corby)
Jopling, Rt Hon Michael	Rathbone, Tim
Kellett-Bowman, Dame Elaine	Redwood, Rt Hon John
Key, Robert	Renton, Rt Hon Tim
King, Rt Hon Tom	Richards, Rod
Kirkhope, Timothy	Riddick, Graham
Knapman, Roger	Rifkind, Rt Hon Malcolm
Knight, Mrs Angela (Erewash)	Robathan, Andrew
Knight, Greg (Derby N)	Roberts, Rt Hon Sir Wyn
Knight, Dame Jill (Bir'm E'st'n)	Robertson, Raymond (Ab'd'n S)
Knox, Sir David	Robinson, Mark (Somerton)
Kynoch, George (Kincardine)	Roe, Mrs Marion (Broxbourne)
Lait, Mrs Jacqui	Rowe, Andrew (Mid Kent)
Lamont, Rt Hon Norman	Rumbold, Rt Hon Dame Angela
Lang, Rt Hon Ian	Ryder, Rt Hon Richard
Lawrence, Sir Ivan	Sackville, Tom
Legg, Barry	Sainsbury, Rt Hon Sir Timothy
Leigh, Edward	Scott, Rt Hon Sir Nicholas
Lennox-Boyd, Sir Mark	Shaw, David (Dover)
Lester, Jim (Broxtowe)	Shaw, Sir Giles (Pudsey)
Lidington, David	Shephard, Rt Hon Gillian
Lightbown, David	Shepherd, Colin (Hereford)
Lilley, Rt Hon Peter	Shepherd, Richard (Aldridge)
Lloyd, Rt Hon Sir Peter (Fareham)	Shersby, Michael
Lord, Michael	Skeet, Sir Trevor
Luff, Peter	Smith, Sir Dudley (Warwick)
Lyell, Rt Hon Sir Nicholas	Smith, Tim (Beaconsfield)
MacGregor, Rt Hon John	Soames, Nicholas
MacKay, Andrew	Speed, Sir Keith
Maclean, David	Spencer, Sir Derek
McLoughlin, Patrick	Spicer, Sir James (W Dorset)
McNair-Wilson, Sir Patrick	Spicer, Michael (S Worcs)
Madel, Sir David	Spink, Dr Robert
Maitland, Lady Olga	Spring, Richard
Major, Rt Hon John	Sproat, Iain
Malone, Gerald	Squire, Robin (Hornchurch)
Mans, Keith	Stanley, Rt Hon Sir John
Marland, Paul	Steen, Anthony
Marlow, Tony	Stephen, Michael
Marshall, John (Hendon S)	Stern, Michael
Marshall, Sir Michael (Arundel)	Stewart, Allan
Martin, David (Portsmouth S)	Streeter, Gary
Mates, Michael	Sumberg, David
Mawhinney, Rt Hon Dr Brian	Sweeney, Walter
Mayhew, Rt Hon Sir Patrick	Sykes, John
Mellor, Rt Hon David	Tapsell, Sir Peter
Merchant, Piers	Taylor, Ian (Esher)
Mills, Iain	Taylor, John M (Solihull)
Mitchell, Andrew (Gedling)	Taylor, Sir Teddy (Southend, E)
Mitchell, Sir David (NW Hants)	Temple-Morris, Peter
Moate, Sir Roger	Thomason, Roy
Monro, Sir Hector	Thompson, Sir Donald (C'er V)
Montgomery, Sir Fergus	Thompson, Patrick (Norwich N)
Moss, Malcolm	Thornton, Sir Malcolm
Needham, Rt Hon Richard	Thurnham, Peter
Nelson, Anthony	Townend, John (Bridlington)
Neubert, Sir Michael	Townsend, Cyril D (Bexl'yh'th)
Newton, Rt Hon Tony	Tracey, Richard
Nicholls, Patrick	Trend, Michael
Nicholson, David (Taunton)	Trotter, Neville
Nicholson, Emma (Devon West)	Twinn, Dr Ian
Norris, Steve	Vaughan, Sir Gerard
Onslow, Rt Hon Sir Cranley	Viggers, Peter
Oppenheim, Phillip	Waldegrave, Rt Hon William
Ottaway, Richard	Walden, George

Walker, Bill (N Tayside)	Wilkinson, John
Waller, Gary	Willetts, David
Ward, John	Wilshire, David
Wardle, Charles (Bexhill)	Winterton, Mrs Ann (Congleton)
Waterson, Nigel	Winterton, Nicholas (Macc'fld)
Watts John	Wolfson, Mark
Wells, Bowen	Wood, Timothy
	Yeo, Tim
Wheeler, Rt Hon Sir John	Young, Rt Hon Sir George
Whitney, Ray
Whittingdale, John	Tellers for the Ayes:
Widdecombe, Ann	Dr. Liam Fox and
Wiggin, Sir Jerry	Mr. Sydney Chapman.
NOES
Abbott, Ms Diane	Corbyn, Jeremy
Adams, Mrs Irene	Corston, Jean
Ainger, Nick	Cousins, Jim
Ainsworth, Robert (Cov'try NE)	Cox, Tom
Allen, Graham	Cummings, John
Alton, David	Cunliffe, Lawrence
Anderson, Donald (Swansea E)	Cunningham, Jim (Covy SE)
Anderson, Ms Janet (Ros'dale)	Cunningham, Rt Hon Dr John
Armstrong, Hilary	Dafis, Cynog
Ashdown, Rt Hon Paddy	Dalyell, Tam
Ashton, Joe	Darling, Alistair
Austin-Walker, John	Davidson, Ian
Banks, Tony (Newham NW)	Davies, Bryan (Oldham C'tral)
Barnes, Harry	Davies, Rt Hon Denzil (Llanelli)
Barron, Kevin	Davies, Ron (Caerphilly)
Battle, John	Davis, Terry (B'ham, H'dge H'l)
Bayley, Hugh	Denham, John
Beckett, Rt Hon Margaret	Dewar, Donald
Beith, Rt Hon A J	Dixon, Don
Bell, Stuart	Dobson, Frank
Benn, Rt Hon Tony	Donohoe, Brian H
Bennett, Andrew F	Dunnachie, Jimmy
Benton, Joe	Eagle, Ms Angela
Bermingram, Gerald	Eastham, Ken
Berry, Roger	Enright, Derek
Betts, Clive	Etherington, Bill
Blair, Rt Hon Tony	Evans, John (St Helens N)
Blunkett, David	Ewing, Mrs Margaret
Boateng, Paul	Fatchett, Derek
Boyes, Roland	Faulds, Andrew
Bradley, Keith	Reid, Frank (Birkenhead)
Bray, Dr Jeremy	Fisher, Mark
Brown, Gordon (Dunfermline E)	Flynn, Paul
Brown, N (N'c'tle upon Tyne E)	Foster, Rt Hon Derek
Bruce, Malcolm (Gordon)	Foster, Don (Bath)
Burden, Richard	Foulkes, George
Byers, Stephen	Fraser, John
Caborn, Richard	Fyfe, Maria
Callaghan, Jim	Galbraith, Sam
Campbell, Mrs Anne (C'bridge)	Galloway, George
Campbell, Menzies (Fife NE)	Gapes, Mike
Campbell, Ronnie (Blyth V)	Garrett, John
Campbell-Savours, D N	George, Bruce
Canavan, Dennis	Gerrard, Neil
Cann, Jamie	Gilbert, Rt Hon Dr John
Carlile, Alexander (Montgomery)	Godman, Dr Norman A
Chidgey, David	Godsiff, Roger
Chisholm, Malcolm	Golding, Mrs Llin
Church, Judith	Gordon, Mildred
Clapham, Michael	Graham, Thomas
Clark, Dr David (South Shields)	Grant, Bernie (Tottenham)
Clarke, Eric (Midlothian)	Griffiths, Nigel (Edinburgh S)
Clarke, Tom (Monklands W)	Griffiths, Win (Bridgend)
Clelland, David	Grocott, Bruce
Clwyd, Mrs Ann	Gunnell, John
Coffey, Ann	Hain, Peter
Cohen, Harry	Hall, Mike
Connarty, Michael	Hanson, David
Cook, Frank (Stockton N)	Hardy, Peter
Cook, Robin (Livingston)	Harman, Ms Harriet
Corbett, Robin	Harvey, Nick

Hattersley, Rt Hon Roy	Meale, Alan
Henderson, Doug	Michael, Alun
Hendron, Dr Joe	Michie, Bill (Sheffield Heeley)
Heppell, John	Michie, Mrs Ray (Argyll & Bute)
Hill, Keith (Streatham)	Milburn, Alan
Hinchliffe, David	Miller, Andrew
Hodge, Margaret	Mitchell, Austin (Gt Grimsby)
Hoey, Kate	Moonie, Dr Lewis
Hogg, Norman (Cumbernauld)	Morgan, Rhodri
Home Robertson, John	Morley, Elliot
Hood, Jimmy	Morris, Rt Hon Alfred (Wy'nshawe)
Hoon, Geoffrey	Morris, Estelle (B'ham Yardley)
Howarth, George (Knowsley North)	Morris, Rt Hon John (Aberavon)
Howells, Dr. Kim (Pontypridd)	Mudie, George
Hoyle, Doug	Mullin, Chris
Hughes, Kevin (Doncaster N)	Murphy, Paul
Hughes, Robert (Aberdeen N)	Oakes, Rt Hon Gordon
Hughes, Roy (Newport E)	O'Brien, Mike (N W'kshire)
Hughes, Simon (Southwark)	O'Brien, William (Normanton)
Hume, John	O'Hara, Edward
Hutton, John	Olner, Bill
Illsley, Eric	O'Neill, Martin
Ingram, Adam	Orme, Rt Hon Stanley
Jackson, Glenda (H'stead)	Parry, Robert
Jackson, Helen (Shef'ld, H)	Patchett, Terry
Jamieson, David	Pearson, Ian
Janner, Greville	Pendry, Tom
Johnston, Sir Russell	Pickthall, Colin
Jones, Barry (Alyn and D'side)	Pike, Peter L
Jones, leuan Wyn (Ynys Môn)	Pope, Greg
Jones, Jon Owen (Cardiff C)	Powell, Ray (Ogmore)
Jones, Lynne (B'ham S O)	Prentice, Bridget (Lew'm E)
Jones, Martyn (Clwyd, SW)	Prentice, Gordon (Pendle)
Jones, Nigel (Cheltenham)	Prescott, Rt Hon John
Jowell, Tessa	Primarolo, Dawn
Kaufman, Rt Hon Gerald	Purchase, Ken
Keen, Alan	Quin, Ms Joyce
Kennedy, Charles (Ross,C&S)	Radice, Giles
Kennedy, Jane (Lpool Brdgn)	Randall, Stuart
Khabra, Piara S	Raynsford, Nick
Kilfoyle, Peter	Redmond, Martin
Kirkwood, Archy	Reid, Dr John
Lestor, Joan (Eccles)	Rendel, David
Lewis, Terry	Robertson, George (Hamilton)
Litherland, Robert	Robinson, Geoffrey (Co'try NW)
Livingstone, Ken	Robinson, Peter (Belfast E)
Lloyd, Tony (Stretford)	Rogers, Allan
Llwyd, Elfyn	Rooker, Jeff
Loyden, Eddie	Rooney, Terry
Lynne, Ms Liz	Ross, Ernie (Dundee W)
McAllion, John	Rowlands, Ted
McAvoy, Thomas	Ruddock, Joan
McCartney, Ian	Salmond, Alex
McCrea, The Reverend William	Sedgemore, Brian
Macdonald, Calum	Sheerman, Barry
McFall, John	Sheldon, Rt Hon Robert
McKelvey, William	Shore, Rt Hon Peter
Mackinlay, Andrew	Short, Clare
McLeish, Henry	Simpson, Alan
Maclennan, Robert	Skinner, Dennis
McMaster, Gordon	Smith, Andrew (Oxford E)
McNamara, Kevin	Smith, Chris (Isl'ton S & F'sbury)
MacShane, Denis	Smith, Llew (Blaenau Gwent)
McWilliam, John	Snape, Peter
Madden, Max	Soley, Clive
Maddock, Diana	Spearing, Nigel
Mahon, Alice	Spellar, John
Mallon, Seamus	Squire, Rachel (Dunfermline W)
Mandelson, Peter	Steel, Rt Hon Sir David
Marek, Dr John	Steinberg, Gerry
Marshall, David (Shettleston)	Stevenson, George
Marshall, Jim (Leicester, S)	Stott, Roger
Martin, Michael J (Springburn)	Strang, Dr. Gavin
Martlew, Eric	Straw, Jack
Maxton, John	Sutcliffe, Gerry
Meacher, Michael	Taylor, Mrs Ann (Dewsbury)

Taylor, Rt Hon John D (Strgfd)	Welsh, Andrew
Taylor, Matthew (Truro)	Wicks, Malcolm
Thompson, Jack (Wansbeck)	Wigley, Dafydd
Timms, Stephen	Williams, Rt Hon Alan (Sw'n W)
Tipping, Paddy	Williams, Alan W (Carmarthen)
Touhig, Don	Wilson, Brian
Trimble, David	Winnick, David
Turner, Dennis	Wise, Audrey
Tyler, Paul	Worthington, Tony
Vaz, Keith	Wray, Jimmy
Walker, Rt Hon Sir Harold	Wright, Dr Tony
Wallace, James	Young, David (Bolton SE)
Walley, Joan
Wardell, Gareth (Gower)	Tellers for the Noes:
Wareing, Robert N	Mrs. Barbara Roche and
Watson, Mike	Mr. Jim Dowd.

Question accordingly agreed to.

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

Resolved, That this House noting that the problems of London's health service have been the subject of at least 20 reports in the last 80 years, all of which have come to broadly similar conclusions, believes that a better service for patients lies in implementing decisions and not a further review; commends the Government for its record in investing in modern hospitals, first class specialist centres and primary care and for its determination to take necessary decisions in the long term interest of the Capital's health service and the people of London; and calls on the Government to ensure that the decisions are now carefully carried forward taking due account of concerns that they should be properly paced so that patients continue to benefit from new and better services before old ones close.