St. Mark's Hospital, London

HL Deb 12 July 1991 vol 530 cc1667-94

3.50 p.m.

Lord McGregor of Durris rose to ask Her Majesty's Government what is their policy for the future of St. Mark's Hospital in the City Road, London.

The noble Lord said: My Lords, when the noble Baroness, Lady Masham of Ilton, asked the Government on 25th June whether there were plans to close St. Mark's Hospital in City Road, London, so much anxiety was expressed on all sides of the House that it seemed appropriate to enable your Lordships to consider the future of this small hospital at greater length than was possible at that time.

St. Mark's is a notable institution which celebrated its sesquicentenary in 1985. Over many decades it has reinforced a worldwide reputation for diseases of the rectum and colon, a reputation created by a fusion of clinical experience, research and teaching. St. Mark's has become a centre of intellectual radiation in its fields of clinical practice and study. Its annual report for 1990 shows that the 30 consultants produced 162 papers in scientific journals, 27 chapters in books, and had a hand in the publication of seven text books, either new or in revised editions. Five surgeons from St Mark's lectured and demonstrated last year at 25 different hospitals in all parts of the world. No wonder that this small institution within the administrative jurisdiction of the City and Hackney health authority is regarded at home and abroad as a unique centre of excellence. Moreover, a high level of patient care has been part of this achievement.

The noble Lord, Lord Rea, has asked me to say how much he regrets that unavoidable absence deprives him of the opportunity to speak of the comfort which his patients derive from St. Mark's and their anxieties about its future. Your Lordships will have seen that the noble and learned Lord, Lord Shawcross, wrote in the same vein to The Times yesterday.

For the past 15 years St. Mark's has experienced insecurities arising from uncertainties about its future. In 1977, 1982 and today there have been proposals from the health authorities to remove the hospital to a new site. Everyone agrees that the present location is unsatisfactory as a result, among other circumstances, of old buildings, present fire hazards and inadequate provisions for intensive care and anaesthesia.

St. Mark's is not wedded to its Victorian shrine in the City Road and will be happy to move to more suitable. premises provided—and this is the crux of the matter about which all the staff feel passionately—that its separate identity and integrated facilities for clinical work, research and teaching are preserved; for those make up the foundation upon which its quality and repute have been built and now rest.

I do not intend to rehearse the past and sometimes abrasive history of negotiations between St. Mark's and its district authority. I attended a meeting this week at which the chief executive of that body, Dr. Grant, said that the conclusion of its clinical policy group was that: Unless the finance could be found to allow St. Mark's to move on to or adjacent to [another] site in such a way that it could retain its own identity, it should be left where it is". Dr. Grant gave me permission to quote his conclusion which he has put to the regional authority; so there is now common ground among those immediately involved.

What is proposed is that the district will seek £1 million to tackle the outstanding backlog of maintenance consisting primarily of measures to ensure fire safety. This minimum of capital work will allow St. Mark's to stay on its present site for a further four or five years while the district puts together the finance to allow it to move to a new building. It is hoped that this new building will be at or adjacent to St. Bartholomew's Hospital. In fact St. Mark's and Bart's are far advanced in discussions about a future connection which might include bringing a range of specialisms into a new institute of gastroenterology, with which St. Mark's, while retaining its separate clinical, research and teaching identity, could be closely associated.

So far, therefore, it seems that a breathing space has been secured to enable proper and detailed planning for the future of St. Mark's to be undertaken. This proposal is strongly backed by Professor Lesley Rees, the Dean of Bart's medical school, and Mr. James Thomson, the clinical director of St. Mark's. St. Mark's is not an expensive hospital. It has only 74 beds but last year performed 1,300 operations and 1,000 endoscopies at an expenditure of £3.5 million. Securing its future will not involve significant increases in expenditure but will call for new administrative flexibility to meet the unusual recruitment of patients; a recruitment which is thus described in the annual report by the clinical director. He writes: we receive patients from a wide area of the country and a given district which refers patients one year may not need to do so in another year. We are therefore dependent on extra-contractual referrals … to ensure adequate funding. During 1990 approximately one third of our in-patients were from our own North East Thames Region (with less than 5 per cent. from our own District). The remainder (64.5 per cent.) came from all the other regions (105 of the 193 districts) Wales, Scotland, Northern Ireland … but with a strong emphasis in the South of England".

It is not therefore surprising that the district health authority, charged with securing medical services for its own small area of population, should think of, small specialist hospitals [as] something of an anomaly within the framework of the acute hospital services". This anomaly has in some cases been dealt with by conferring on such specialist hospitals as Moorfields, the Brompton, the Maudsley, Broadmoor, the Eastman Dental Hospital and several others, the status of special hospital authorities which deal directly with, and obtain their funding from, the Department of Health. I understand, though, that the future of such special health authorities is in doubt after 1993.

Other specialist institutions have not been so fortunate as those I have mentioned. Their experiences have raised sharp anxieties among those at St. Mark's attempting to plan the transition from the City Road to a new location at Bart's or elsewhere. I have time to cite only one instance—what has happened to the hospitals of St. Peter's, St. Paul's and St. Philip's and the Shaftesbury Hospital, which perform specialist referral functions in nephro-urology akin to the functions of St. Mark's in respect of intestinal disorders.

The St. Peter's Hospitals likewise possess high international repute with, I am told, no equivalent elsewhere in the world. In 1988, when the Bloomsbury health authority announced the early relocation of St. Peter's Hospitals into the Middlesex site, it was stated that all services would be supplied and managed by the Middlesex Hospital. The Minister, the department, the regional manager and, subsequently, the district manager and St. Peter's agreed that, the siting and management of these services should enable the St. Peter's group to continue to function as an identifiable whole". In discussion at that time it was agreed that the management of the clinical support services should remain associated with the management of the St. Peter's clinical services as a functional whole.

Yesterday I received a letter from Mr. Roger Henderson, QC from which, with his permission, I shall now quote. He writes: I was appointed by the Secretary of State as the Chairman of the Special Committee"— that is, the special committee dealing with the relocation of the St. Peter's Hospitals— in succession to Stewart Bates QC on his elevation to the Bench. My tenure of office was intended to last at least until the relocation of the 3 P's had been satisfactorily implemented. My letter of appointment was expressed to be until the end of March 1991. I was somewhat diffident about seeking re-appointment and therefore thought it right that the matter should be raised by Sir Alan Greengross, the Chairman of the District Health Authority, and by the doctors of the 3 P's on the Special Committee. They duly wrote on a number of occasions to ask the Secretary of State to extend my tenure, but have received no response whatsoever, despite the fact that the vital elements of relocation have not been finalised, and there is increasing concern that there will be seriously deficient arrangements". In general, the committee has been unable adequately to fulfil all the purposes for which it was established. According to Mr. Henderson's letter, among persisting difficulties the region is still, seeking to require the 3 P's to take [radiological] equipment which will fail to meet [their] essential requirements". In the light of that experience, the fears about St. Mark's are not phantoms; they are a realistic assessment by reasonable people of its possible future.

I shall not weary the House with comments upon the problems of applying the intention that money shall follow the patient to a hospital like St. Mark's, which attracts some two-thirds of its patients from all over the United Kingdom. An administrative structure as inevitably complicated as that of the health service must contain such conflicts as may at present afflict divisional health authorities and specialist postgraduate hospitals of international standing in their areas. Those conflicts should not be inflated into abrasive disputes, because neither the district nor the region can be blamed for situations which only the Government can regulate.

It is not my present purpose to criticise or, for that matter, to praise the Government's new policies for the NHS, beyond saying that if they cannot deal with the important, though limited, problem which I have attempted to outline, they will have to be revised. At this stage there are more mysteries than certainties in the outlook for St. Mark's. No doubt the most promising development would be an association with Bart's which preserves St. Mark's separate identity and clinical, research and teaching functions, although such special funding as might be conferred by the status, or something similar, of a special health authority would be essential.

Who can predict the future of Bart's—a teaching hospital of the University of London—and whether or not it becomes a trust? My only question to the Minister is whether he will put to his right honourable friend the Secretary of State the importance and urgency of his receiving a delegation to discuss St. Mark's and thus to secure a stable framework for its planning over the next three or four years during which the district has agreed to maintain it on its present site.

St. Mark's is an outstanding British achievement, created by generations of medical dedication, research and intellectual excellence. Surely the Secretary of State will not permit its destruction by administrative and unimaginative shortsightedness. I have spoken as a patient who has benefited from the knowledge developed at St. Mark's. I believe that this is a subject on which the voice of the patient should be heard. That is in the interests of those who will need treatment in the years to come. I am sure, too, that this is a subject to which the Secretary of State should devote his personal attention.

4.9 p.m.

Lord Beloff

My Lords, the whole House is indebted to the noble Lord, Lord McGregor of Durris, for tabling this Question. The importance attached to it by your Lordships is shown by the large number of speakers at this intolerably late hour on a Friday.

My wish to make a brief contribution arises from having followed the arguments of the noble Lord, Lord McGregor, with which I entirely agree, and from my feeling that it was worth stating in the House how disappointed the House was on 25th June when the Question was last asked, when it appeared that the Minister had not been fully briefed and was not in a position to explain what was going on between the district and St. Mark's. As we all know, she is a devoted and dedicated Minister, but that she was clearly unaware of the full ramifications of the problem is disturbing. It is like the failure of important people to receive a reply from the Secretary of State about the other hospital to which the noble Lord, Lord McGregor of Durris, referred. I myself in my modest way wrote to the Secretary of State about the problem and have not received a reply.

It seems to me that the problem reflects not only the future of this important hospital—I have no medical qualifications for saying any more on that—but also on the Government's general capacity to fit into their health reform general principles (which I find acceptable) the particular problem of a small number of specialist hospitals. They are specialist not only in the treating of patients but also in research and training for this country and overseas. As I say, the problem reflects on the capacity of the Government to fit the se hospitals into the pattern of the health service which is naturally and rightly to some extent dictated by the distribution of population through regions and districts. There are not many such hospitals but they are of great importance to the future of the health service and to the health of the country. They confer great distinction internationally upon the country.

In other areas of government, the distinction between what is for local provision and what is of national importance is fully recognised. No one would suggest that the new British Library should be concerned only with the reading habits of the residents of Camden. No one suggests that the University of Oxford should confine its attention to the inhabitants of Oxfordshire. Yet we received the Answer that the whole responsibility lay with the City and Hackney health authority. Its expenditure on St. Mark's comes to about 2 per cent. of its budget and naturally enough it provides only a tiny trickle of patients, who, because of the nature of their maladies, are drawn from all over the country.

I cannot believe that it is beyond the wit of the Government to devise a system by which those hospitals that have been designated already should retain that status and St. Mark's should clearly be added to their number. As the noble Lord, Lord McGregor, pointed out, it is desirable for the future that the hospital should benefit by attachment to another teaching hospital which is also involved in undergraduate teaching. No hard and fast divisions should exist in the fields of teaching and research. St. Bartholomew's, for geographical reasons if for no others, seems appropriate. The principle should certainly be that a hospital of this kind should be treated as an institution which must retain its identity and, where possible, be in a location where its needs are fully served.

I very much hope that the Minister who will reply today will be able to tell the noble Lord, Lord McGregor, that the Secretary of State will personally receive people who can put him in the picture. Otherwise, the whole reputation of the National Health Service reforms will suffer as a result of something that is tiny, in the budgetary and administrative picture taken as a whole, but which for the medical world is very important both for itself and as a symbol.

4.15 p.m.

Lord Motley

My Lords, I very much endorse what the noble Lord, Lord Beloff, said, particularly as regards the congratulations he offered to the noble Lord, Lord McGregor, on introducing this matter. It is remarkable that so many noble Lords are present at this hour on a Friday. The number of noble Lords who are present underlines the importance that we attach to the future of St. Mark's.

I wish to concentrate on the future of St. Mark's. I am sorry that the noble Baroness, Lady Hooper, cannot be present today. However, she replied to a Written Question that I tabled on 3rd July. I asked that the decision on the future of the hospital should be taken by Ministers and not by the health authority concerned. I also asked for an undertaking that no such decision would be taken in a parliamentary recess. The answer did not refer to the future. It stated: The provision of health services … is a matter for City and Hackney Health Authority".—[Official Report, 3/7/91; col. WA69.] The Minister also stated that the health authority would follow the normal consultation procedures once a decision had been made. In Whitehall vernacular that means that Whitehall does not want Ministers to interfere. It is a good thing for the Government if a health authority takes a decision. If there is a big row the Government do not have to take any responsibility for the decision. One could infer from that position that the Secretary of State is not really interested in these matters and that his officials regard him as a personalised rubber stamp. We all know that that is far from being the case. The Secretary of State is intelligent and has a distinguished—one might almost say brilliant—scholastic record. He will be only too well aware of the virtues of research and scholarship.

I am simply asking why Ministers should not take these decisions. As far as I am aware, there is no statutory arrangement for pursuing matters of this kind. However, that is not the case as regards planning law which is very complex. There are provisions whereby the Secretary of State can call in matters of other than purely local importance for his personal consideration and decision.

In the medical world, St. Mark's is the equivalent of a Grade I listed building in the architectural world. In that case why on earth should the Minister, or preferably the Secretary of State, not call the matter in for his own consideration? I can understand that the Department of Health may not want to prohibit decisions being taken during a parliamentary recess. It may hope that with the passage of time anger will die away and the matter will be easier to handle. I remind your Lordships that the regional board we are discussing had to be overridden by Mrs. Currie, the Minister at the time, when it proposed to remove a radiotherapy provision from Southend hospital and transfer it to a place that was almost impossible for patients from the Southend area to reach. Happily, the decision was overruled and the difficulty did not arise. However, it was only overruled after a lengthy parliamentary campaign.

I hope that the number of patients treated at the hospital will be taken into consideration in this case. The noble Lord, Lord Beloff, said that the allocation for St. Mark's accounts for only 2 per cent. of the health authority's expenditure. Nevertheless there is no particular reason why the health authority should feel responsible for financing a hospital of international importance. I am advised that St. Mark's is the only hospital anywhere in the world that gives training in colopractology as distinct from general surgery. The noble Lord, Lord McColl, will correct me if I have used the wrong term. Its research into hereditary aspects of cancer of the bowel has been of immense importance. Consultants almost everywhere specialising in this field have been trained at St. Mark's.

I hesitate to say this in the absence of the noble Baroness, who has another engagement and whose commitment to her responsibilities and to the health service I do not doubt, but when she spoke on 4th July she appeared to suggest that it was the number of treatments which mattered. I suggest that if a few days in St. Mark's makes it possible for someone to have cancer removed and therefore live a longer life, that is more important statistically than someone being treated for sunburn in a casualty department in the unlikely event of our having a heat wave in this country. I hope that the number of treatments will not count for too much, but if it does, I hope that the number of tests which St. Mark's undertakes on potential patients with a hereditary risk of cancer will count. I am sure that that will place the hospital in a favourable position in relation to other hospitals.

In 1948 the late Aneurin Bevan who, despite lacking the benefit of a Harvard or Oxford education, had an instinctive wisdom to which I can personally testify, and indeed, he was richly endowed in that respect, separated St. Mark's and other similar research and postgraduate hospitals from the general hospitals. Later, in 1974, special hospital authorities —but not St. Mark's, and I do not know why—were placed in a special category. The simple answer is for St. Mark's to have that status now and to be accountable directly to the Department of Health. I believe that the intention is that the Department of Health should act as a regional board for the special hospital authorities. That would make a great deal of sense.

The noble Lord, Lord Beloff, made a very telling remark when he said that it would be absurd if Oxford University had to be financed by the citizens of Oxford. That would be a total nonsense. If such a lunatic proposal were to be put forward and carried, I am sure that there would be a demand —probably led by the present Secretary of State and, if not, certainly by the noble Lord, Lord Beloff—that All Souls should have a special exemption as a centre of excellence. In medical terms St. Mark's is equivalent to All Souls, although it does not have the material comforts or elegance of that marvellous establishment in Oxford University.

In education it is well recognised that the funding of universities should not be tied to residents or fall under any jurisdiction except an independent one funded by the Exchequer. That principle has recently very properly been extended to polytechnics and colleges of further education which also draw their students from a wide field. As already stated, St. Mark's probably draws only 3 per cent. or 4 per cent. of its patients at most from the area of the City and Hackney health authority. I therefore endorse the statements which have been made that it is essential for St. Mark's to be independent and that it should not only have its own budget but also be accountable for that money directly to the Department of Health and nowhere else. I have some doubts about the suggestion of the noble Lord, Lord McGregor of Durris, that that can be arranged with Bart's. That would be dangerous because—

Lord McGregor of Durris

My Lords, it was not my suggestion that St. Mark's should have a close association with Bart's. It was the suggestion of St. Mark's and Bart's which I was reporting to the House and which I was given permission to report.

Lord Mulley

My Lords, I intended to remark only that it was a suggestion that the noble Lord had put before us and to mention the reasons for not wishing that to happen. It would not be more than a few years before the merger meant that it would be impossible to retain the reputation, identity and facilities of St. Mark's. Admittedly my experience is second-hand—I have no doubt that the noble Lord, Lord McColl, has much experience of this—but I understand that when it comes to fighting for scarce resources, as is sadly the case in hospitals, consultants striving to achieve their beds and sessions in operating theatres make the ambitions of politicians seeking a safe parliamentary seat look like the work of mere amateurs. It is therefore essential that St. Mark's should have a separate international identity. We are throwing away 150-odd years of international reputation. It must have the facilities and beds at its disposal. It would disintegrate if it were to be otherwise.

As this is an important matter and it is desirable that all aspects are canvassed, I hope that the Secretary of State will agree, as already proposed by the noble Lords, Lord McGregor and Lord Beloff, to receive a small deputation when the matter can perhaps be examined in greater detail. I hope that we shall have an affirmative response from the Minister on that point. I had given the noble Baroness, Lady Hooper, notice that I intended to raise some of these points, but I understand that she is not able to be present today.

4.27 p.m.

The Lord Bishop of Peterborough

My Lords, I am grateful to the noble Lord, Lord McGregor of Durris, for his cogent opening of the debate. I speak with no specialist medical knowledge, nor as an ex-patient, but as one who has known many people who have been through the hospital and whose lives have been transformed by the treatment that they have received, as is the case with so many hospitals. An interesting point that has not been made is that the hospital deals with the second biggest killer by cancer after lung cancer. Cancer of the rectum and colon is the second biggest killer among men and this hospital deals with it.

The problem is that the other specialties have a certain fashionableness about them. When one considers the amount of money spent on the treatment of lung cancer and the associated advertising and the small amount spent here and the small amount asked for, one realises that often in medicine, as in all other things including the Church, what is popular and fashionable runs through our society. The rectum and colon have inevitably never been fashionable and popular.

It is sad that this hospital, which has been a pioneer since the 1920s, did not share in the opportunities afforded to Moorfields, the Maudsley and the National Hospital in Queen Square, which also deal with specific specialties, and that it did not have the same designated status which has to a degree protected those others from the situation that has developed at St. Mark's. It is difficult both for the local district and for the area to deal with the problem. In this case that is the regional authority and the City and Hackney Health Authority. One does not wish to make the debate going on in London any more difficult.

Speaking as one who comes from further afield I ask why one always has to consider London as the best place for such hospitals. The city is so monstrously expensive at every level of activity. Sometimes one wonders why there are not important places of this kind associated with major hospitals in what we laughingly call the provinces, where development could grow at much less cost in a wider space.

Ken McKee, one of the two pioneers of hip replacements, was for many years a member of my congregation when I was a vicar. He in Norwich and Charmley in Wigan were the pioneers of an operation which is now done worldwide. Moreover, it is done by registrars, not by the most senior consultants. That is now absolutely normal. To begin with the operation was performed in two provincial hospitals. Even with the monstrously complex back-up that is required for some forms of cancer treatment, one wonders why we should be trapped into a "London debate". It may be necessary, however, and, if so, one accepts it.

I mentioned Ken McKee and Charnley because they were names of my youth. They are now largely forgotten except through books. They pioneered a whole series of treatments in complex development which meant so much to so many, including, as I look around this Chamber on a packed day, many who appear from the way they walk to have shared in that particular experience, some of them more than once. Having known those people who led the way, I believe that St. Mark's is in very much the same situation. Forty per cent. of its referrals are tertiary—it is like the National, the Maudsley and Moorfields hospitals. When the very best elsewhere cannot manage treatment, patients see St. Mark's as almost the last point to which to refer. It is absolutely key for the country.

An American once described St. Mark's as a Mecca. After some of the debates in this House, that is an unfortunate label to place upon the hospital, but it shows how a man who came from what is probably the most medically sophisticated nation in the world regarded it. It would be a tragedy if it followed the way of the 'three Ps". I used to live in Bloomsbury and in my time there the feeling about the disappearance of hospitals there and the way in which they had been treated still lingered and will always linger. One hopes and believes that the same will not be allowed to happen here. Therefore I support other noble Lords in requesting that close attention at the highest level be given to this matter.

4.32 p.m.

Baroness Gardner of Parkes

My Lords, I was most interested to hear the debate and I am grateful to the noble Lord, Lord McGregor, for bringing forward this topic. I visited Iceland as a Member of this House on an official visit and was met by people who trained at St. Mark's. They spoke very highly of it. They still, to this day, refer patients to St. Mark's. I knew the building—the exterior, not the interior—because my dental surgery was just around the corner, and I was there for over 30 years.

Many interesting points have been raised. I was fascinated by the suggestion of the right reverend Prelate that a place in the provinces might be desirable. I believe that as time goes by that will happen increasingly in the future. London hospitals are facing the problem of losing the population around them and costs in London are particularly high.

The point mentioned by the noble Lord, Lord McGregor, about extracontractual referrals are a cause of great anxiety for everyone in a teaching institute at the present time. Many patients would prefer to be treated nearer to home and more regions with different places in the country are now able to carry out treatments. As a result, the highly specialised hospitals suffer from receiving only the extremely difficult cases while their overheads and costs rise. It makes it that much more difficult if they do not have some bread and butter work as well. The point made by the right reverend Prelate about possibly seeing some hospitals moving out of the capital has to be considered.

I have expressed my personal views. However, I am vice-chairman of the regional health authority for this hospital. I therefore believe it important to establish the region's position. The regional health authority is very aware of the high quality of the treatment and research carried out at St. Mark's and fully supports its desire to retain a separate identity and to continue its excellent work. There has been general agreement that St. Mark's should relocate eventually into St. Bartholomew's Hospital.

However the problem is that the region is not in a position to fund such a move at the £17 million level requested by St. Mark's. Indeed, in the current climate the region would have difficulty even to fund the £6 million suggested by the City and Hackney health authority. Noble Lords may know that the region has had to cancel the forward capital programme because of the decline in property values. Those were a factor in the calculations. The sale of surplus land was to have played a major part in financing new developments and improvements and that was in addition to the government allowance of about £70 million a year that we receive. Without doubt, the value of the St. Mark's site will also have been affected.

As the noble Lord, Lord McGregor, stated, there was talk of allowing St. Mark's to remain where it is. I understand that the district health authority is now considering such a course. The regional health authority could allow that only if the building was safe. Suggestions have been made today and at other times that the building is unsafe. That is a matter that must be checked. Safety is of great importance. However, the regional health authority can give no commitment to refurbish the present building which is very old.

The issue of special health authority status is interesting. The region has no views as to whether the hospital should achieve special health authority status or become a national health trust. That is purely a matter for the department.

I speak now wearing not my regional hat, but my personal hat. For 15 years I served as a member of the special health authority concerning the Brompton and National Heart Hospital. We had a slightly similar situation. For years people were treated in a very old building, the National Heart Hospital, in Wimpole Street. On occasions when I inspected the hospital, I felt that it indicated how good the treatment must be that people were prepared to come to such an old place which required much attention. The state of the building does not seem to affect the quality of patient care. However, last week I visited the newly-built Brompton and National Heart Hospital. There is no doubt that when one rehouses those marvellous institutes in places of high standard it makes a tremendous difference to the morale of not only everyone working there but also of the patients who like to be treated in better surroundings. However, the difficulty for the regional health authority is financial.

4.38 p.m.

Lord Desai

My Lords, I do not speak on this subject as an expert, or as someone who has enjoyed the facilities of the hospital. I live locally. However, St. Mark's is not just a local London hospital but a national and international facility.

The age of the building, safety and other arguments require us to consider whether we should move St. Mark's to another location or rebuild and refurbish it. There are medical reasons for saying that St. Mark's should be adjacent to, but certainly not part of, another hospital. Those are clearly important considerations.

More importantly, however, I must emphasise the uniqueness of a small, internationally famous research-oriented hospital. I know from experience in the university sector that such establishments are extremely hard to maintain. They are easily destroyed and never recovered. In the long run it proves to be more economic to maintain them than to find replacements for them. I sincerely believe that even on the grounds of long-term economy we should examine carefully the case for keeping St. Mark's as it is under whatever arrangements are most suitable. We should give it such supplementary help as is necessary but we should not lose its unique identity or quality.

During the recent National Health Service reforms many interesting ideas were put forward about choice and the different ways of financing national health. I do not wish to comment upon those but to point out that a hospital such as St. Mark's is unique. It has a niche role in the provision of specialist facilities; it is not a supermarket. Ultimately people must go to that hospital and if such a facility were dissipated it would be more expensive to provide the same service on a one-off basis at regional hospitals.

I hope that, whatever course is adopted—either the interim plan of refurbishing St. Mark's present building and eventually moving it adjacent to, though not making it part of, another hospital, or the erection of a new building —the issue will be treated as a national priority and not dealt with at regional health authority level.

4.42 p.m.

Baroness Masham of Ilton

My Lords, our debate about St. Mark's Hospital in the City Road continues after my Starred Question tabled on Tuesday 25th June, which had support from all sides of the House. Again today we have all-party support. I thank the noble Lord, Lord McGregor of Durris, for carrying on the debate.

We are talking about a small hospital which has become renowned for its excellence not only throughout Britain and Europe but throughout the world. Indeed, it is known by specialists throughout the medical universe who work in the field of diseases of the rectum and the colon as "The Holy of Holies of the Back Passage".

Excluding noble Lords who have taken part in the debate today I know four patients who have benefited from the expertise at St. Mark's. One is a young man in his 20s who had a peri-anal fistula. He was treated in a Birmingham hospital, where he was operated on without success. Some time later he was again operated on in a hospital in Darlington, County Durham, where he was admitted twice. Between hospitalisation he received mammoth doses of antibiotics but with no success. Finally the surgeon sent him to St. Mark's for the treatment of his recurring and persistent problem. He was operated on and discharged within a week, since when he has had no problems. That is typical of the results of St. Mark's Hospital.

Another case is that of a woman from Norfolk who was transferred by her Norfolk surgeon for treatment of a complicated fistula. She was cured by the late Sir Alan Parkes, a surgeon at St. Mark's. The third patient I know to be transferred was a high-lesion tetraplegic who had undergone numerous unsuccessful operations at Stoke Mandeville Hospital, Buckinghamshire, on a complicated recto-vaginal fistula. St. Mark's was the last resort and, happily for her, the treatment was successful. The remaining patient was from Yorkshire and suffered from inflammation of the bowels and an unknown shadow. After investigation at St. Mark's, the situation was resolved.

Some 40 per cent. of its patients are tertiary referrals; that is, patients referred from other hospitals throughout the United Kingdom and from abroad. St. Mark's is a major research centre with an international reputation for its work. Some 650 visitors from all over the world come to it every year. Many senior registrars working in its specialty, which is very important, as many of your Lordships know only too well, are trained there and that training is then spread across the country. As consultants they then teach other doctors and nurses the high quality methods used at St. Mark's.

It is obvious to all who understand and appreciate the National Health Service that St. Mark's Hospital is a national resource and not a local issue. Funding should be decided at a national level and not at district or regional level.

All concede that St. Mark's Hospital must move but that it must be maintained and properly funded as a specialist intestinal unit. For over 150 years St. Mark's has been situated in City Road. It has only 74 beds but it performs 1,300 operations and 1,000 endoscopies yearly and 75 per cent. of its medical staff are consultants, who in the past five years have published between them 575 scientific papers and 28 books on their specialties.

Does that excellent record not now deserve a new hospital? Ideally it should be placed on the campus of a teaching hospital which has all the back-up services. It seems important that it should have intensive care services and full anaesthetic cover. It deserves that and it is in the interests of the country that it should become directly answerable to the Department of Health as should other specialised supra-regional or national units.

When community health councils were established, I served on one. I then moved on to serve on a regional health authority which had 17 districts. With the recent reorganisation of the health service I have been anxious about many of the specialised units. When only about 3 per cent. of the local population uses a specialised unit, it is understandable that the community health council does not show particular interest. Therefore, those hospitals or units of national or supra-regional status are without the full support of community health councils.

It is understandable also that health districts may not be very interested because they are interested in the local population. In time, when the funding scheme of the money following the patient begins to work, it may work very well but it will not work if the patients follow the money. I shall be grateful if the Minister will give an assurance today that there will not be delays for tertiary referrals. That is of the utmost importance to patients who have serious complications.

St. Mark's Hospital deals with serious medicine. It has a discipline and procedure which patients must follow. We hear so much party political talk about waiting lists but the sort of work which goes on at St. Mark's Hospital is far too serious to become a party political issue. Patients who have had their lives saved at St. Mark's know how important that is.

Every year there is a tragic loss of life from cancer. It is through dedicated medical personnel coming together with research facilities that advancement can be ma de against cancer and other complicated conditions. That research must go on and expand.

It is difficult to get across the message of how vital these specialist places are when government Ministers such as the noble Baroness, Lady Hooper, are lucky enough never to have been ill or to have been a hospital patient. Perhaps today we have in the noble Lord, Lord Cavendish, a Minister who will convey our anxiety to the Secretary of State.

It is about time the Government gave these centres of excellence like St. Mark's a pat on the back rather than, like Pontius Pilate, shrugging and saying, "Let the district or region decide". The work carried out at St. Mark's under conditions that are far from ideal is an example of achievement. It is inconceivable that anyone could think of dismantling such an operation. That is why a team of your Lordships has gathered on a Friday afternoon to give support to St. Mark's, which leads the Western world in the treatment of and research into intestinal diseases, including cancer. Even though in time St. Mark's may be rebuilt on an ideal hospital site—wherever that may be—opinion seems to be unanimous that it should stay intact and independent as a special health authority or its own trust. It does not want to be swallowed up and perhaps disembowelled.

Whenever there is a threat of closure or a NHS reorganisation I become concerned at the time spent in meetings and discussions while patients are waiting for treatment. With this threat to St Mark's it must be the patients who feel most confused and worried. The National Association for Colitis and Crohn's Disease was founded and inaugurated at St. Mark's in November 1979. There are now over 16,000 members. For those suffering from Crohn's Disease, St. Mark's has been a saviour. I hope that the Minister will be able to give some assurance to those patients that their support will not disappear and that the words written by the Government, "patients first", are sound and not hollow.

It is a pleasure to work with noble Lords who have an interest in St. Mark's. I take this opportunity of thanking all the expert people working there for providing such an excellent standard of care; long may it last.

4.53 p.m.

Lord McColl of Dulwich

My Lords, perhaps I may add my thanks to the noble Lord, Lord McGregor, for initiating this debate about which I ought to declare more than a passing interest. I worked at St. Mark's from 1958 to 1964 and retain a great affection and respect for that outstanding institution. It has been encouraging to hear of the high esteem in which your Lordships hold St. Mark's. Certainly wherever one travels in the world everyone has heard of its reputation.

During the past 10 years two of the presidents of the Royal College of Surgeons have been consultants at St. Mark's—the late Sir Alan Parks and more recently Sir Ian Todd. Many of its consultants during the past 50 years have been household names in the medical profession. One of the most distinguished gastro-enterologists at St. Mark's for many years was Sir Francis Avery Jones, who is well into his eighties and as brilliant as ever.

The problem we are discussing today, as your Lordships have said, concerns also the other small specialist hospitals like the urology hospitals, St.

Peter's, St. Paul's and St. Philip's—known affectionately to many noble Lords as the three Ps. One has to see the future of all those hospitals in terms of what is happening nationally. Since 1965 approximately 7,000 beds have been closed every year irrespective of which government have been in power. There is a steady decline in the number of beds. That simply reflects the substantially reduced length of stay which is now thought desirable and the fact that half the operations in general surgery can and should be done on a day-case basis.

In the 1970s it was agreed by all the political parties that the resources on the hospital side of the National Health Service had to be redistributed more fairly throughout the country. With the declining population in London that inevitably meant that resources would be moved out. In turn, that would mean a reduction in the total number of hospitals. We have had a great increase in technology, both in diagnosis and treatment, and it is quite clear that we cannot have large numbers of hospitals packed into a small area, each having all the high-tech facilities, including intensive care. Moreover, we are quite rightly obliged to reduce the total number of hours worked by junior staff.

All these policies—agreed by all parties—inevitably mean that amalgamation of more London hospitals will have to occur. The secret of success in this movement is at all costs to try to preserve the identity of these hospitals with their international reputations. It would be ideal if some way could be found for them to have separate buildings within the curtilage of the larger teaching hospitals.

It should be said that there will be advantages in some of these amalgamations. Both the undergraduate and postgraduate hospitals will thereby be stimulated to achieve greater heights, especially in some of the fast developing specialties like genetics and immunology. Another possibility which is being actively considered is whether some of the postgraduate hospitals should amalgamate to become self-governing hospitals as it is quite clear that some of them could thereby stand on their own feet.

There is overwhelming support for St. Mark's to continue to flourish and whatever plans are being discussed I very much hope that its identity will be preserved: preserved in name, with its own budget and if at all possible with its own building within the curtilage of one of the other hospitals rather than being sunk without trace in one floor of a large institution.

As the noble Lord, Lord McGregor, said, those at St. Mark's who are charged with negotiating at this time are all reasonable, charming and rational people. I hope that they will be heard at the highest level.

4.58 p.m.

Lord Butterfield

My Lords, I should like to thank the noble Lord, Lord McGregor, for bringing this debate to us, even on a Friday. It is not a Test Match day so it will be all right.

Perhaps I may say that the noble Lord brilliantly presented the factual side of the St. Mark's case. I do not think that any noble Lord could improve on the form of the arguments he presented. However, there are one or two small points that I should like briefly to explore. Before I do so, perhaps I may also say that while I lavish praise on the noble Lord, Lord McGregor, I also give great accolades of praise to all the other speakers. My former student, the noble Lord, Lord McColl, distinguished himself this afternoon with his speech.

I can see that there may be constraints on the department at the moment because of the administrative routes between districts and regions and concerning recognised teaching hospital status. However, at the end of the day all of us who are clinicians, and, I, suspect, the nation as a whole, are wondering whether this small part of the NHS—St. Mark's, the three Ps and the others, which are cutting edges in the quality of care in the NHS—will be given what the rest of us see as equal consideration to that given in the recognisable past to the purchase of computers on a large scale for the accounting side of the NHS and the development of very many new posts for the management side of the NHS. In a way we are looking now—the noble Baroness, Lady Masham, made this point—for a sign that the Department of Health puts high in its priorities places where high quality care is developed. That is an important aspect of the present exchange of views. I realise that, because of the administrative cogs that must turn, the department may have to wait a little while before it can say much. But at the end of the day, if it lets down St. Mark's, many of us will feel, sadly, that the espousal of excellence in the health service is beginning to slip away.

I do not want to go too far in regard to the right reverend Prelate the Bishop of Peterborough—I come from nearby Cambridge—but I should like to try to explain why there are so many postgraduate institutes in London. It is relevant to the relationship which will, I hope, develop between St. Mark's, Bart's and wherever else. In the Victorian era, physicians of great general diagnostic skill, great therapeutic power and powers of persuasion were becoming specialists in diseases of the heart, the lungs, the nerves and so on. They began to realise that they had practically no prospect of training in a general hospital the support services that they wanted for their kind of cases. The nurses passing through the teaching hospitals had to become general nurses. The matron would not leave them to deal with heart cases for the whole of their year in medicine. Therefore, the physicians quite rightly struck out for themselves and founded the Brompton Hospital, the Queen's Square Hospital, the Maudsley Hospital, a great centre for the study of mental diseases; and some of them set up St. Mark's in City Road.

One therefore must not be surprised that from the Victorian and Edwardian eras right up until the health service came to distribute our medical care equally over the whole country, people got into trains and came to London for that fateful second opinion, for an operation or for treatment. If it was a special type of treatment they would find their way to those specialist hospitals.

After the setting up of the health service the specialist hospital had to protect its educational status, with research and teaching activities going on in postgraduate institutes. One of the great sadnesses to me is that St. Mark's seems to have lost its postgraduate institute status. I shall come back in a moment to why I think that is important. To return to my point, it was because the great hospitals, from whose loins sprang the postgraduate institutes, were in London where the population was a great stew of human disease that one finds so many of the elderly specialist hospitals here in London. However, the right reverend Prelate is quite right that many of the new developments are likely to be located on the periphery. Noble Lords who have heard me speak on this subject will know how anxious I am that the Department of Health should not put at hazard the wonderfully uniform health service that we have all over the country. That is one of our greatest triumphs. When one visits America and one sees that nearly 50 million people—that is almost the population of England and Scotland—do not have access to a doctor one realises why youngsters like myself hold on to the triumph of the developments which came with the health service.

I believe is most important that I should explain that I am not too unhappy about the idea of St. Mark's being lodged in St. Bartholomew's Hospital. I take that view because, when St. John's Hospital for Diseases of the Skin in Leicester Square wished to relocate, a deal was struck that it would relocate in St. Thomas' Hospital. It is now my great privilege to be the chairman of the united medical and dental schools of Guy's Hospital and St. Thomas' Hospital. Therefore, I know a little about the movement of St. John's into St. Thomas' Hospital. That move was much helped by the fact that St. John's had a postgraduate institute under the umbrella of the University of London. By bringing it in to St. Thomas', we got all the salary scales right and the whole thing clicked into place like a change of gear.

I do not think that the people of St. John's felt that the move was quite so simple. However, we also received money from the site. How sad it is that the value of land has tailed away. But that money allowed the governors of St. Thomas' to gut and spend many millions of pounds—I am not sure how much was involved, but I suspect that it was in the order of £10 million—in refurbishing a part of St. Thomas' to set up the Institute of Dermatology. St. John's Hospital was lodged inside St. Thomas' with its own status and its own teachers who came from the original building. When Her Royal Highness the Princess Royal visited last yea r I had just been made chairman. I was very proud to be able to show her the beautifully refurbished accommodation for the dermatologists.

Poor St. Mark's seems to me to be in trouble because it does not have such a splendid dowry. If it did, those concerned could look St. Bartholomew's Hospital straight in the eye and say, "We can take care of many of our own requirements." Just as specialist hospitals sprung from the loins of the old teaching hospital, I wonder whether it would be fair if they returned now to save their parents who are having a very hard time because of the redistribution of the population. People no longer have to come from Birmingham to London for a second opinion. However, not much harm would be done—and I believe that the noble Lord, Lord McColl, shares this view—if there was a consolidation in the great teaching centres.

Administratively speaking, small hospitals are expensive. For example, some apparatus is not in constant use. The possibility of having intensive care, high-powered radiological, new magnetic resonance-type of investigations in bowel disease in a big centre like Bart's, with a big throughput of students who inevitably stimulate the research workers, seems to me to be a wonderful prospect; that is, if we can get it.

It means that the Minister's department would have to be as enthusiastic about the idea as everyone else has been in the House today. It would also mean that we would have to embrace the concept of a St. Bartholomew's/St. Mark's institution. It is possible that we may even have to embrace a rugby football team with the name of St. Mark's stitched on to the rugger shirts. I do not mind what we have to do, provided that those men from St. Mark's are happy in their new environment.

In conclusion, I should like to say how conscious I am of the importance of these small hospitals to the NHS. That is why we are all here today. We feel that they are absolutely vital for the ongoing elevation of the standards of care in the health service. I received a lovely letter from an old Oxford friend, Mr. Richard Turner-Warwick, who is a surgeon at the London University Institute of Urology to which reference has been made. I shall plagiarise his last paragraph. He says that he is not seeking my personal support for the Specialist Hospitals in general". or for his own hospital—although, as a matter of fact, he has it; and I believe he knew that before he wrote to me. He continues, but I want to assure you that their contribution to the National quality of our Health Service is indeed threatened and in need of more appropriate protection". That is why I came here today from Cambridge to plead with the Minister.

5.10 p.m.

Lord Carter

My Lords, the House is grateful to the noble Lord, Lord McGregor of Durris, for tabling the Question. We have had an excellent debate on an important topic. The ground has been well and expertly covered, and so I can be brief. All speakers have agreed that St. Mark's is a hospital of national and international importance which provides a magnificent service to its patients from this country and from abroad. We all know that "a centre of excellence" is a phrase which is sometimes misused, but it applies to St. Mark's.

As the noble Lord, Lord McGregor, said, what happens to St. Mark's will be a true test of the value of the NHS reforms. It will show whether, under the reforms, a hospital of that nature can maintain its integrity and identity as a separate unit. As has been pointed out, it is the only hospital in the Western world which is dedicated solely to the treatment of intestinal diseases.

One way, and perhaps the best way, to secure the future of St. Mark's, is for it to become a designated teaching hospital like other comparable specialist hospitals. It will be interesting to learn whether the Minister agrees that that will be the best solution. With 65 per cent. of St. Mark's patients coming from outside the North East Thames Regional Health Authority area and 97 per cent. from outside the City and Hackney DHA area it is clear that a major financial and administrative anomaly will result—it has resulted—if the hospital is not treated as a valuable national resource, which is what it is. From listening to the debate, it seems that the future of the hospital cannot be planned if it has to fit within the capital and budgetary restraints of one DHA.

One solution mentioned by a number of speakers is a move to a new site at Bart's Hospital. There is much to be said for that solution; but, as we all agree, it is the maintenance of St. Mark's as a separate clinical, teaching and research centre that is crucial. The question is much more than one of mere estate management. I emphasise that St. Mark's and Bart's are considering a proposal to which at present both are attracted, but that is subject to a range of caveats. Both recognise that any arrangement which did not ensure a separate functional identity for St. Mark's would be unacceptable.

As we are all aware, it is a question not of buildings but of funding. The problems for the DHA or RHA are considerable. We can sympathise with the managers. They are trying to implement the NHS reforms; they are struggling with their budget; and they are trying to catch up with the backlog of maintenance and safety work. That amounts to £19 million for St. Mark's and Bart's alone. With all those problems with which to deal, the temptation over time to cut into St. Mark's budget will be more than any regional or district manager could resist if such a specialist unit remained within his budget. The Government should do their best to remove that temptation.

The situation is further complicated by the high proportion of St. Mark's patients who come from outside the district and the region. The figures have already been quoted. Will the Minister say whether my understanding of the situation is correct? I live in Wiltshire, and before the reforms, if I needed the special care given by St. Mark's, I could be referred there by my GP or, more likely, by the appropriate consultant at my district or regional hospital, just as, for example, a member of my family was referred by our GP to Bath, then to Bristol, and eventually to Great Ormond Street and Moorfields for separate conditions. Can I now be referred to St. Mark's only if my DHA has a contract with St. Mark's, or if it does not have a contract is prepared to use part of its limited extra-contractual referral budget to send me there'? If my GP is a budget-holder he can presumably do a deal with St. Mark's direct.

A number of your Lordships have referred to the Starred Question put down on 25th June by the noble Baroness, Lady Masham. The Minister replied to the noble Lord, Lord Walton of Detchant. She said: We believe that because this specialist treatment is so well known and recognised, St. Mark's will continue to attract patients and, as a result of the National Health Service reforms, the income will follow". My noble friend Lady David referred to postgraduate visitors from overseas. The Minister again said: The well-deserved reputation of St. Mark's is such that it will inevitably attract income, including, I hope, income from overseas". Finally, in response to the noble Baroness, Lady Robson of Kiddington, who asked: Should the Department of Health not make it a special health authority and fund it centrally", the Minister's response was: My Lords, under our reforms we offer the possibility that in the case of services which continue to attract patients, as a national resource of this kind can, the income will follow". —[Official Report, 25/6/91; cols. 488–490.] If that is the case, then I draw your Lordships' attention to the report in the Guardian today: Hospital patients are having their medical notes marked with a bright yellow £ sign if there is a question over whether the person's district health authority will pay for treatment.

"The fluorescent stickers, bearing the £ sign and the words Non Contract Case, are being attached to files at the Royal Victoria Hospital, Bournemouth, to identify patients from districts with which the hospital does not have fixed contracts". The report continues: Districts are supposed to have set aside money for such 'extra-contractual referrals,' mainly for cases where GPs want to send patients outside the local district, but most authorities have budgeted only small sums and these are already heavily depleted in some cases". That is obviously crucial in the context of St. Mark's which takes many of its patients from outside either the district or the region. It is important for the Minister to spell out exactly how this will work with St. Mark's as it is so heavily dependent on outside referrals.

Before a final decision on St. Mark's can be taken, there are a number of questions which must be satisfactorily answered. The Minister will be aware that I informed him before the debate that I would ask these questions. At the outset I can say that from these Benches I support the suggestion by a number of noble Lords that the Secretary of State should receive a deputation to consider the future of St. Mark's.

Does the Minister agree that, in addition to the deputation, an expert working party should be set up to consider the future of St. Mark's and other national referral teaching centres? The problem has been referred to by a number of speakers. The working party could see how these very valuable units can best fit into the new pattern of NHS care. Will the department agree to contract directly with St. Mark's to enable it to become a designated teaching hospital on the lines of an SHA? Such a step would protect the national teaching, research and referral role of the hospital. If it has to remain within the RHA and the DHA and their budgets do not allow sufficient funds to secure the future of St. Mark's, is the department prepared to make up the shortfall from central funds?

Can the Minister explain why St. Mark's is different from the other specialist London hospitals which have been referred to by a number of noble Lords: Moorfields, Great Ormond Street, the National Hospital for Nervous Diseases, the Brompton Hospital, the Maudsley and the Eastman Dental Hospital? They all have an international reputation for clinical care, research and teaching in specialist fields exactly the same as St. Mark's.

I do not propose to go back over the ground so excellently covered by all speakers in the debate. Every aspect has been thoroughly explored. We must hope now that the Minister can provide an answer from the Government which will properly secure the future of this outstanding example of the very best of clinical care in teaching and research.

5.18 p.m.

Lord Cavendish of Furness

My Lords, I join others in thanking the noble Lord, Lord McGregor of Durris, for introducing the debate. I also wish to thank noble Lords for their patience in waiting so long. It is a reflection of the importance of the debate that they have done so. The noble Lord, Lord Winstanley, demonstrating another unique quality of St. Mark's which has not come up, wished to add to the debate and apologised to me for being unable to be present. No one could have heard the debate without attaching enormous importance to the support that exists for the hospital. It was difficult not to be moved by the strength of feeling evident on all sides of the House.

The question of St. Mark's future was raised in your Lordships' House on 25th June and has received considerable coverage in the press. Such interest is certainly evidence of the support for the hospital and of the esteem in which it is held. The noble Lord, Lord McGregor, asks what is Her Majesty's Government's policy for the future of St. Mark's. What is at issue, however, is not government policy, but the possible outcome of local discussions which are currently taking place. There is no doubt about the valuable specialist services and postgraduate training provided by St. Mark's.

Various noble Lords have asked me questions. I received advance notice of some of those questions and I am grateful for that. In reply to questions asked by the noble Lords, Lord McGregor and Lord Carter, I was asked whether a working party could be set up to consider the options for St. Mark's. I believe that that matter can be considered. I was also asked whether a delegation could visit Ministers. I feel sure that my noble friend Lady Hooper and my right honourable friend the Secretary of State will be happy to consider any representations which noble Lords may wish to make.

The matter of special health authority status for St. Mark's is an issue that I shall return to later. As regards funding, it is a matter for the regional health authority to determine its capital priorities. The RHA will wish to consider all demands on its capital. It would not be right this afternoon for me to pre-empt its decisions or speculate on the merits of those decisions.

I have also been asked about the effects of NHS reforms. St. Mark's is internationally recognised for its work in the field of colo-rectal diseases, including cancer, irritable bowel syndrome, Crohn's disease and ulcerative colitis. It has also started a register of patients with familial polyposis coli. That register has now been expanded to a large number of other hospitals. The hospital treats patients from all over the country and 50 per cent. of its patients are referred from other UK hospitals. The NHS reforms ensure that where there is a need and a demand for services those services will continue. I say that mindful of the comments of the noble Baroness, Lady Masham, on hold-ups to tertiary referrals.

As my noble friend Lady Hooper has already made clear in answer to the noble Baroness, Lady Masham, on 25th June, there are no plans to close St. Mark's. However, a dialogue between the health authorities and the hospital has been taking place for a considerable time. The dialogue has been about the benefits of providing facilities elsewhere. This discussion has been positive, with recognition by all parties of the advantages of relocating St. Mark's.

The noble Lord, Lord Desai, was in favour of refurbishment of the hospital on its present site. I do not wish to enter that discussion but I understand that that view is held by some people. The clinical director of St. Mark's has recorded the staff's welcome of the opportunities flowing from a move to a new site, provided such a move does not destroy the integrity of the hospital. The discussion has not been about whether St. Mark's should relocate, but about the cost and scale of such an exercise.

I should like to provide some background to these discussions, and to go over the reasons for looking at relocation as an option. The current location of St. Mark's Hospital on a separate site, isolated from other acute provision and facilities, is a cause for concern. Indeed small specialist hospitals have increasingly looked to the advantages accruing from integration in the framework of acute health services. I shall return to this point later. In recent years, as medical technology has become increasingly sophisticated, the problems associated with being a small specialist hospital on a site separate from a general acute facility have become more apparent. Although St. Mark's Hospital provides a wide range of high quality specialist services, it looks to other parts of the district's hospital services, and particularly to St. Bartholomew's Hospital, for a number of support services.

The condition of the St. Mark's buildings is another important factor. Given the age of the buildings it is perhaps not surprising that the physical layout of services and facilities does not match modern standards. There is no doubt that the site is crowded. Much of the space is inefficiently used, being taken up by corridor and staircase space, and services are spread across many levels.

The condition of the buildings leaves much to be desired. The fabric of the buildings has now outlived operational use as a hospital. Substantial redevelopment, both external and internal, is required to address issues of functional suitability, building and plant refurbishment, usage of space, fire safety and compliance with health and safety regulations. Considerable expenditure would be needed to bring the buildings up to modern standards of acceptability.

A third factor in considering St. Mark's future is the adequacy of its facilities. As I said, St. Mark's, although offering high quality specialist services, lacks a number of desirable support services. No one disputes that. For instance, the hospital has no special provision for the care of the critically ill. Those patients are currently treated on the general wards or in the theatre recovery area. Patients requiring intensive care often face a transfer to another site. I believe that we would all agree that having to move such vulnerable patients is extremely undesirable. In addition, pathology services and the provision of out-of-hours anaesthetic services are extremely limited at St. Mark's. There is little scope to improve those services on the present site.

Discussions are taking place with the health authorities, and I would not wish to pre-empt any decision. The noble Lord, Lord Mulley, asked why Ministers could not make decisions. I have tried to convey the fact that at present Ministers cannot make decisions because there are systems in place for dealing with these matters.

Lord Mulley

My Lords, I thank the noble Lord for giving way. Whereas in planning, for example, there is a large body of legislation laying down what has to be done, so far as I know there is nothing in the health service legislation which requires the process which the Minister is now describing to be undertaken. It is entirely an administrative matter.

Lord Cavendish of Furness

My Lords, with great respect to the noble Lord, my advice is that that is not the case. As I understand it, we are obliged to allow the present procedures to run their normal course.

Lord Mulley

My Lords, we have not been given any legislative reference. I have asked for that.

Lord Cavendish of Furness

My Lords, unless I receive some advice I cannot give such a reference.

As I shall explain more fully later, decisions may in any case need to be considered by the Secretary of State. It may be helpful, however, to look at the advantages of one of the options under consideration. The relocation of St. Mark's Hospital to St. Bartholomew's could provide solutions to some of the problems which have been outlined. There would be a better infrastructure for supporting the clinicians in their invaluable work. They would benefit from the extra resources available at Bart's, with all the facilities of a multi-specialty acute hospital. Bricks and mortar alone do not make a hospital; it is the quality of the services which is most important. However, when the fabric of a building is in such condition that it hinders the efficient delivery of the service, one must look at the costs of bringing the building up to scratch. In the case of St. Mark's it is estimated that over £4 million would need to be spent on essential backlog maintenance. The possibility of relocation must seem an attractive option when one considers the financial savings which it would represent—money which could then be spent by the health service to provide better patient care.

There has been some questioning about the possibility of St. Mark's being in some way managed centrally. That point was mentioned by the noble Lords, Lord McGregor and Lord Mulley, and others. The whole thrust of the NHS reforms has been to encourage greater devolution of management. The reforms seek to delegate responsibility to the local level as far as possible. That includes delegation of functions from regions to districts, and from districts to hospitals and units. Hospitals will be more responsible for running their own affairs. The consideration of extending central management runs counter to the reforms.

When the London Advisory Group recommended the creation of the special health authorities in 1981, not all special hospitals were thus reconstituted. Some were not included because they were too small to be managed as a separate entity, because they did not have a postgraduate institute or because they needed rebuilding. Those criteria have not changed. Therefore, to respond to my noble friend Lord Beloff, rather than adding to the number of existing special health authorities we are considering how best they can fulfil their functions in the new NHS. It is not therefore appropriate to add to their number. That is not the way forward.

On the question of research—this matter was raised by the noble Baroness, Lady Masham—there are surely benefits in relocating St. Mark's to a teaching hospital with well-established postgraduate medical education and research. I understand that Bart's currently has funding for education and research amounting to 20 per cent. of its total budget. Regions will be developing their plans as part of the recently announced comprehensive NHS strategy and programme for R&D. Regions are likely to consider what is done at St. Mark's and other similar hospitals as they develop their plans.

The identity of a hospital is an issue on which noble Lords feel strongly. It was perhaps the matter to which most reference was made. But need that identity be lost? I emphasise that the discussions that have been going on for some considerable time are concerned with finding solutions to St. Mark's problems, not with wanton destruction of its value or identity.

Relocation need not be seen as a threat to a hospital's identity. A similar situation has arisen with the relocation, nearing completion, of another small, single-specialty group of hospitals which has been mentioned. The St. Peter's group is a renowned centre for the treatment of benign as well as malignant diseases of the kidney, bladder and urinary tract. It also embraces the Institute of Urology. From January 1992 the group will be re-housed within the Middlesex Hospital. In other words, its situation parallels that of St. Mark's considering a move to St. Bartholomew's Hospital.

There may be lessons to be learned from that, but there is a certain amount of conflicting reporting here. In contrast to the quotation used by the noble Lord, Lord McGregor, from Mr. Henderson, the Chairman of St. Peter's Medical Committee and the Dean of the Institute of Urology have recently written to colleagues in the medical fraternity giving advance notice of the move. They have written of the advantages of the better facilities that they will enjoy, the potential for close collaboration with the medical school, and the opportunities and benefits of working in a multi-specialty environment. Such a positive view of the relocation of specialist services may well encourage those who see only dangers in the discussions about the future of St. Mark's. Considerable thought is being given to ways in which St. Mark's identity may be protected; for example, its name, its operation of its own budget, a separate medical records function and its own medical executive committee.

As I emphasised at the outset of this debate, there are no plans for the closure of the hospital. There has, however, been some concern about the way in which proposals may emerge. Perhaps I may reassure the House about the normal process for dealing with proposals for either closure or significant change of use of health buildings.

It is the responsibility of the district health authority to come up with proposals and to consult the community health council. The CHC is a group appointed to represent the users of the health service. If CHCs do not agree with the district's proposals, they are free to put forward their own proposals. District health authorities should also consult widely with MPs, local authorities and other interested bodies like the family health service authorities. District health authorities must carefully consider any CHC proposals, as well as any other comments that they receive, alongside their own plans.

Lord Carter

My Lords, will the noble Lord explain how the 65 per cent. of St. Mark's patients who come from outside the area of the regional health authority will be able to transmit their views to the CHC so that they can be taken into account in its response?

Lord Cavendish of Furness

My Lords, I cannot explain that, but one cannot always get round that in any event. Wherever a specialty exists, one cannot always have the widest possible consultation. It always devolves to an area to deal with what is best in that area. To that extent, we do not live in a perfect world. If the noble Lord can come up with a better suggestion, I am sure that it will be considered.

The regional health authority may support the CHC, in which case the district would have to look at its plans again and revise them accordingly. If the region supports the district's plans, they are sent to Ministers of the Department of Health for a final decision. Ministers become involved when agreement cannot be reached between the CHC and the local health authority. They take into account all views and make the decision that they believe is in the best interest of the health service.

I have spent some little time on the process for considering the proposals in order to reassure your Lordships that decisions cannot be taken in a cavalier fashion Consultation is an integral part of the process and at all levels there must be consideration of views and opinions. Should any plans be put forward in which interested parties disagree, there would be ample opportunity for those views to be expressed. A decision would need to take account of them and of the interests of the health service as a whole.

I believe that I have answered one or two questions as I have gone along but there are some outstanding ones to which I should like to reply. The noble Lord, Lord Carter, asked about the mechanism for referring patients to St. Mark's. GPs are free to refer patients to a hospital whether or not their district has a contract with that hospital. In an emergency, patients will always be treated immediately. In less urgent cases it will be up to the district to consider, in the light of all its priorities, whether patients can be treated straightaway or whether they may have to wait a little.

The noble Lord, Lord McGregor, asked about the future of the SHAs, suggesting that it may not be secure after 1993. There are commitments for continuing essential funding of London postgraduate SHAs after April 1991. Ministers will be considering what arrangements will be most appropriate in the future.

My noble friend Lady Gardner and the right reverend Prelate said that we should not be obsessed with keeping things inside London, to which I agree. We are likely to see increasing development of services outside London. Indeed, that has been the policy of successive governments, recognising the shifting population away from London. Changes need to be managed carefully, taking into account, for example, the advantages of a specialist hospital being located in or near a teaching hospital.

My noble friend Lord McColl asked about trust status. The background is that in July 1990 a trust application was received from the proposed City and Hackney Trust. The proposed trust included St. Mark's Hospital and the application proposed that St. Mark's should transfer to the St. Bartholomew's site, which retained a distinct identity. The proposal, which would have involved capital investment of over I6 million, was supported by the senior clinicians of St. Mark's.

My right honourable friend the Secretary of State for Health did not establish the City and Hackney Trust, although he expressed confidence that it had the potential to become a successful trust in the future. One of the reasons why he did not feel able to establish it was that the effect of the capital plans on the unit's costs and prices would have rendered it uncompetitive. The City and Hackney has revised the capital plans and as part of that revision believes that the transfer of St. Mark's can be achieved at a much lower cost than the £16 million originally proposed.

The trust project team of City and Hackney are currently considering whether to resubmit the application this year. Senior clinicians of St. Mark's will need to decide whether they wish to be included in the trust proposal or whether they prefer to seek trust status as a separate entity. Either option is open to them. St. Mark's is a small hospital and in considering whether to apply separately it would need to consider carefully whether the hospital's income was sufficient to cover its costs and overheads including the capital cost of the current hospital's buildings which have a high capital value and will be in need of substantial repair if the hospital does not transfer to St. Bartholomew's.

As was said during the debate, St. Mark's draws its patients from a large number of health authorities. It needs to consider the overhead costs of setting up a separate management structure to enable it to cope with the large numbers of service contracts which it would manage.

Finally, on that subject, whether the decision is made to seek trust status separately or to remain within the City and Hackney unit, the application will be subject to public consultation and detailed financial assessment. The Secretary of State will make a decision on the basis of four key criteria: first, the benefits to patients in improvements in the quality of the services—and the proposed trust would deliver them; secondly, the strength and effectiveness of its leadership and management; thirdly, the involvement in management of key professional staff, especially clinicians; and, fourthly, the proposed trust's financial viability. My right honourable friend the Secretary of State and the NHS management executive will offer whatever help and advice they can. However, it is for senior clinicians at St. Mark's to decide what course of action they feel is best.

The noble Lord, Lord Butterfield, gave us a fascinating historical perspective of the development of London hospitals. His observations on hospitals with postgraduate status were of especial interest. He asked whether we are committed to high quality care. The Government fully recognise the importance of centres of excellence producing high quality care. However, we are not convinced that that means providing every service in the same place, as now. Services in London, as in other major centres, are constantly adapting and changing to meet medical advances and changes in the population.

I hope that I have offered some reassurance about the respect in which St. Mark's Hospital is held, and about the discussions which have taken place on options which include housing its valued services in a better location. Those discussions have not yet finished. Other options may emerge. I hope that I have conveyed the feelings of my colleagues on the painstaking procedure which would have to be followed in the event of a proposal for significant change.

My right honourable friend the Secretary of State, and my noble friend Lady Hooper will study with interest what your Lordships said today. They will be left in no doubt about the strength of feeling that the future of St. Mark's inspires. The noble Lord, Lord McGregor, asked that the patient be heard. I assure him that today the patient has been heard.

Lord McGregor of Durris

My Lords, before the noble Lord sits down, perhaps I may take one crumb of comfort from his wide-ranging, if not wholly reassuring, statement; namely, his assurance that Ministers, including the Secretary of State, will receive a deputation to discuss the future of St. Mark's.