Accident and Emergency Services in London

HL Deb 19 June 1991 vol 530 cc238-60

7.55 p.m.

Lord Ennals rose to ask Her Majesty's Government whether they are satisfied with the accident and emergency hospital facilities to deal with terrorist and other emergencies in central London, in view of planned reductions in hospital accident and emergency services.

The noble Lord said: My Lords, on several occasions I have asked Questions in the House about the consequences of the planned closure of the Westminster Hospital and the Westminster Children's Hospital. I am proud to be a Friend of Westminster Hospital. I believe that my subscription is up to date, but I shall check within the next day or two. I was invited to, but had to miss, the recent party at No. 1 Carlton House Gardens, the official home of Mr. and Mrs. Douglas Hurd, but was delighted to see that the Minister, Mrs. Bottomley, said: There are a great many Friends of Westminster Hospital in the Houses of Lords and Commons. It's our local".

Mrs. Bottomley said that, knowing that the "local" was going to be pulled down during the course of the next two years. That party raised £5,500 for the intensive care unit which also, if it is erected, will have to be moved within two years. Tonight I want to concentrate not just on what I believe to be an appalling misjudgment and ghastly waste of money in building a hospital at excessive cost with far too many beds in an unsatisfactory location, but also on the Question on the Order Paper.

Apart from the effect that it will have on the residents of Westminster, the Government are taking a grave risk with the lives of millions of people who work in, or visit as tourists, the heart of London. The area is part of the City of Westminster. The area which I wish to describe has been worked out by town planners. They describe it as a central activities zone of the City of Westminster. There is an official map issued by the Westminster City Council showing its boundaries. The CAZ starts a little to the north of Oxford Street, taking in its great shopping stores; it includes the embassy area of Belgravia; the transport interchange and offices at Victoria; it runs south of Victoria Street to include the several important departments of Government; and has a spur running south to the Tate Gallery and the Embankment. It includes the Palace of Westminster, Whitehall and the Strand, ending at the Royal Courts of Justice and the boundary with the City of London. Consequently, that area includes most of the important places of Government; the major tourist sights, including Buckingham Palace and St. James's Palace; and one of the largest concentrations of retail shopping space in the world.

Due to its nature, the area has few residents, but it attracts daily hundreds of thousands of workers, users and visitors. In bad times, that concentration of people, tourist attractions and centres of government, attract demonstrators, rioters and sometimes terrorists who seemingly see them as an increasingly attractive target.

The only accident and emergency unit now within the CAZ is Westminster Hospital. Outside the CAZ, within a 10-minute journey time from its boundary, there are Bart's Hospital; Guy's Hospital; St. Thomas's Hospital; St. Mary's Hospital; University College Hospital; and, for children, the Westminster Children's Hospital, all with their accident and emergency departments. Any proposal which closes or reduces one of those units inevitably affects 15 per cent. of the major incident cover for the centre of the capital.

The Government have said that the Hammersmith and Charing Cross Hospitals also cover the CAZ, but Hammersmith Hospital is about the same distance (four and a half miles) from the Palace of Westminster as is Canary Wharf in Docklands. Charing Cross Hospital is three and a half miles away. When traffic is normal, that is about 30 minutes in day time traffic.

Twenty years ago there were four accident and emergency units in the centre of a fully equipped teaching hospital. Charing Cross and St. George's hospitals have been moved out, beyond effective reach. In 1986, the Middlesex Hospital closed its accident and emergency department, despite what the Minister said in the House of Lords on 2nd May 1990 and on 7th March 1991. Only Westminster Hospital was left, covering the CAZ from a position within it. Now it is to be closed, regardless of considerations of national emergency.

Since the King's Cross tube station disaster in the late 1980s and the recommendations contained in the subsequent Fennell Report, since 1st January 1989 there have been a significant number of major incidents which have highlighted the requirements which have to be met in coping with any major incident. On 13th January 1989, in the Clapham rail crash more than 30 people were killed and about 150 were seriously injured. The new trauma centre of St. George's hospital coped with about 60 of the victims. Thereafter, the still open accident and emergency department at St. Stephen's coped largely with the balance, with some being sent to the Westminster Hospital and some to Charing Cross. Four units were involved.

On 20th August 1989, the "Marchioness" boat collision occurred with 51 killed and about 80 victims who were not seriously hurt. St. Thomas's was the designated hospital to handle about 50 victims. Westminster Hospital was the first supporting hospital and a total of three units were used to cope. On 31st March 1990 there were the poll tax riots with 339 policemen injured; between 100 and 200 members of the public were hurt. Because the bridges remained closed or clogged from 1400 hours to 1600 hours on that Saturday afternoon, most of the injured were taken direct to the Westminster Hospital from Trafalgar Square and Whitehall. Two units were used because. St. Thomas's was used later in the day.

On 8th January 1991, in the Cannon Street rail crash, one person was killed and several hundred passengers were injured. Three units were used. On 18th February 1991 there was the Victoria station terrorist bombing with one killed and approximately 50 casualties, many seriously injured. Two units were used to cope with that.

All these major incidents like the Harrods and Hyde Park bombings previously—which were also serviced by Westminster Hospital—demonstrated clearly the following twin needs. First, the need for several accident and emergency departments to be available in close proximity to any such major incident. Secondly, there is the need for a speedy ambulance service available to use good spine roads, leading to the accident and emergency hospitals located in suitable places, with good road access. That was 20 years ago. Twenty years ago the capital's centre was properly serviced by five expert teaching hospitals' accident and emergency departments.

I believe that the risk of terrorist and other possible major incidents is greater now than 20 years ago. The recent matters that I have reported prove that. On 18th April 1991, the London ambulance service was advertising for an emergency planning manager on the basis that "major incidents on the scale of King's Cross, Clapham, Cannon Street and Victoria stations are becoming increasingly likely in our complex and sometimes hostile society". Meanwhile, the Government go ahead with plans to close the one remaining hospital accident and emergency centre in this area.

After the planned closure of Westminster Hospital in 1992–93, there will be none of the previous five hospitals, safeguarding the CAZ. The three fringe hospitals will also have been closed.

In July 1988, Westminster City Council conducted its own ambulance journey times experiment with ambulances on site, going from Westminster Cathedral to Victoria Street, both to Westminster Hospital and to the four suggested alternative hospitals after it has been closed. The ambulance took four minutes to reach Westminster Hospital; 10 minutes to St. Thomas's Hospital, 19 minutes to St. Stephen's Hospital; 22 minutes to St. Mary's Hospital; and 26 minutes to University College Hospital. I submit that in many of those cases, patients would have died en route. It is far too long and far too dangerous.

We may learn lessons from examining the care planned by the other emergency services for the centre of the capital. The London Fire Brigade finds it necessary to have Westminster Fire Station in Horseferry Road a few hundred yards from Westminster Hospital. That is, in addition to its Lambeth station, a few hundred yards from St. Thomas's hospital.

The Metropolitan Police are planning a police station on a site once occupied by the Charing Cross Hospital, near Trafalgar Square. The London ambulance service is retaining its Westminster station, a few hundred yards from Westminster Hospital, despite its huge new ambulance station recently opened in Fulham.

How will a major incident of any substantial size, with heavy casualties on the ground, be coped with in the mid-1990s by the NHS, without a Westminster Hospital? I believe the only answer can be that it will be coped with in the best way possible if we do not have adequate provisions. However, it cannot possibly be as well as it is being coped with now and I suppose people will say, "We shall muddle through". I am sure that any emergency or major incident will be coped with by whatever facilities there are. Frankly, that is not good enough; it is not the point. The Victoria station bombing incident proved that because there was swift transport by the London ambulance service. Because the Westminster Hospital was there in close proximity, many lives were saved by speed. I wonder how the Government propose to deal with a major crisis. We could easily have a crisis five or 10 times as bad as those in the past two years which I have listed.

Stepping back a bit, we have no London strategic government. So far as I know, the present Government have no plans to create one, although the plans of the Labour Party have been made publicly clear and welcomed, even by the Evening Standard. It does not welcome many of the things that the Labour Party does.

What about the National Health Service? I wish to ask whether the Minister read the statement by Sir Alan Greengross, a few days ago. He is chairman of the Bloomsbury and Islington Health Authority, a well-known Conservative. He was leader of the Conservatives on the now deceased London County Council. He wrote an article in the Health Service Journal which called for a single capital region. He said, I am concerned that the health service reforms are dismantling vital parts of the framework, particularly in London, and putting nothing in its place". He later said: If the powers that be don't see London as a single entity I do not know how we are going to plan for London. London is a single entity". Having said that London is a single entity, we come to examine how we will cope with the issue of accidents, emergencies and the kind of tragedies that could occur from malicious intent by terrorists or what-have-you. I believe that since there is no London health service nor is there a strategic local authority, the Government must at this stage look at the subject. So I put the Question which stands in my name on the Order Paper. I ask Her Majesty's Government whether they are satisfied with the accident and emergency hospital facilities to deal with terrorist and other emergencies in central London, in view of the planned further reductions in hospital accident and emergency services.

My answer to the Question is that I am by no means satisfied. I believe that the Government are taking a risk. It is a risk at great expense, one that no Government of any capital city should take. It is not just a risk for its residents but a risk for all those other hundreds of thousands of people who work in the central part of London or who come as tourists to our capital. I beg to ask the Question standing in my name on the Order Paper.

8.9 p.m.

Lord McColl of Dulwich

My Lords, I am grateful to the noble Lord, Lord Ennals, for putting down the Question. The most sensible way of trying to answer it is to examine what happens when there is a major disaster in the London area. We are able to do that because on 8th January this year a train ran into the buffers at Cannon Street station. This resulted in 258 casualties. A large number of the casualties—126—came to Guy's Hospital. About five went to St. Thomas's, 106 to St. Bartholomew's Hospital and about 21 to the Royal London Hospital. Of the 258 casualties, 38 were detained in hospital for more than 24 hours while 22 were detained for a little under 24 hours. The rest went home. I was present at Guy's Hospital when the casualties arrived. The reception they received was superb. The casualty department at Guy's is run by Major General Norman Kirby. I have never seen so many doctors and nurses assembled in one place before. Every casualty of the accident who arrived was immediately attended to with great expertise and kindness. All the other ordinary, run-of-the-mill casualties who arrived at the hospital were also treated with great speed and expertise. They were left wondering what had happened.

The news is good news, in that the disaster was well catered for. There was no real problem. As I have already said, St. Thomas's received only about five of the casualties and the Royal London Hospital received only about 27. There is a tremendous capacity there to cope with even bigger disasters.

I have many friends on the medical staff of the Westminster Hospital. It is, of course, traumatic that that hospital is closing, but the decision had its roots in the 1970s with the introduction of cash limits in the National Health Service. The belief grew up that London had too many resources from the NHS and that those resources should be allocated to the provinces. Needless to say, the provinces agreed very much with that policy.

Inevitably as the population of London has declined, it has seemed reasonable to move resources out of London into the provinces. It is fair to say that all the major political parties accepted that policy. Inevitably there will be a decline in the number of hospital beds available in London. Almost every year in the history of the National Health Service there has been a rumpus about the closure of beds. However, since 1965, 7,000 beds have been closed in the National Health Service every year, irrespective of the government in power. Thirty to 40 years ago patients were kept in hospital for far too long. Surgeons did not realise the damage they were doing by that practice. Patients who had gall bladders removed were kept in hospital for two to three weeks. Nowadays they are lucky to be kept in hospital for 24 hours. It is better to get those patients out of hospital and to move them back to their own homes.

The story is even more interesting as regards children. Since 1948 Guy's has had a policy of operating on children and allowing them to go home the same day. That is not done to save money, because it does not save money. It is done because it is the best thing for the children concerned. It is better if patients do not stay in hospital longer than is necessary.

As I have said, it is inevitable that resources will be allocated to the provinces rather than to London and that there will be fewer hospital beds in London. The problem is how we achieve this policy. I wish to draw the attention of the House to the district health authority of Lewisham and North Southwark, in which I work. That district health authority covers an area of 25 square miles and serves a population of a third of a million people. At one time that district had 11 hospitals which all had accident and emergency departments. There was no way in which those accident and emergency departments could continue to be adequately staffed. Clearly we needed to move their facilities into fewer premises. Eventually we hope to condense the facilities into two or three premises. That will be the right number of premises. Even though there are more doctors and nurses in the NHS today than there have ever been, we cannot continue to staff 11 hospitals in that district and provide a full service, including intensive care units. We have to condense those facilities into fewer premises. That is what we are doing.

The Sydenham Children's Hospital is a lovely small children's hospital. It has carried out excellent work over many years and the staff morale at the hospital is very high. The last thing the district health authority wanted to do was to close that hospital but the buildings were falling down and there was no way the staff at the hospital could continue to provide a first-class service. The hospital facilities have been moved into purpose built children's wards at Lewisham Hospital. The facilities at Lewisham Hospital are better than the facilities that existed at the Sydenham Children's Hospital. Parents can sleep in beds adjacent to their children in the children's wards. There is also a sitting-room for the parents and every mod con is available.

We must concentrate on retaining the facilities of such excellent small hospitals as the Sydenham Children's Hospital but we must move those facilities into larger hospitals within the curtilage of the big teaching hospitals. St. Marks Hospital has a worldwide reputation. It is a marvellous hospital that specialises in treating ailments of the lower part of the alimentary tract. Those who have been treated in that hospital for ailments in that part of the anatomy have been tremendously grateful for the services that hospital offers. The local health authority does not wish to close it, as it has a worldwide reputation. The facilities must be maintained, but the building is falling down. Intensive care facilities cannot be offered at that hospital as well as at all the other hospitals in London. Presumably the facilities at St. Mark's will be moved to a hospital such as St. Bartholomew's. The secret of success is to move the facilities into a separate building within the curtilage of St. Bartholomew's. In that way St. Mark's will retain its identity.

I think it is true to say that all the political parties are committed to reducing the number of hours that are worked by junior medical staff. In order to do that the total number of centres that exist in any particular area must be reduced. That is another reason for closing some hospitals and moving their facilities into larger hospitals. I believe London is well able to deal with catastrophes that may occur. The evidence we have at present supports that theory.

8.19 p.m.

Lord Richardson

My Lords, I am greatly indebted to the noble Lord, Lord Ennals, for giving me this opportunity of drawing to the attention of your Lordships a situation that is relevant to our discussion and one that could be remedied easily and relatively cheaply if agreed procedures could be put into effect. I confess to an interest in St. Thomas's Hospital. That interest goes back nearly 60 years.

Members of your Lordships' House refer to St. Thomas's as if it were a very long way away. The psychological effect of the barrier of the river and a very wide bridge seems to be nearly insuperable. The noble Lord, Lord Ennals, said that St. Thomas's was brought in late in the day on one occasion. Why on earth was that? The casualties came from places where they could have been taken to St. Thomas's as quickly as to Westminster Hospital.

The noble Lord also said—I am sure that he was being strictly accurate—that Westminster Hospital was the only hospital providing an accident and emergency service in this area. He then went on to say—and I profoundly agree with him—that London is a single entity. My point is that St. Thomas's is very near to us and is an extremely up-to-date and "with it" hospital.

My problem can be stated briefly. It relates to the effect of the lamented closure of Westminster Hospital. It was realised by many people some years ago that that was almost certain to happen and that local services would have to be met. At St. Thomas's various points were considered and particular interest was directed to the accident and emergency services.

In December 1988 it was agreed with the Department of Health and the regional health authorities concerned at a meeting convened by the Department of Health that there was need for an increase in the size of the St. Thomas's accident and emergency department. The implications of such an increase for the local geography of St. Thomas's present accident and emergency department was also worked out. It was recognised that the workload of the accident and emergency department at St. Thomas's, which at present is 69,000 patients a year, would rise to 104,000 a year in the first year following the closure of Westminster Hospital in October 1992; for various reasons, such as an increasing number of visitors to the London area as a result of the Channel tunnel and so on, by the turn of the century the number of patients would be 120,000.

In order for the essential alterations to be made it was agreed that the two regional authorities concerned on this side of the river—the North West Thames Regional Health Authority and the Riverside Health Authority—and the regional health authority on the opposite side should share the cost of the developments. That was accepted, but unhappily nothing has happened because those authorities claim —and I do not question their claim—that they do not have the money. Therefore no work at all has been done on the provision of the essential structural changes to meet the increased demand. The matter is now one of urgency, quite apart from emergency.

Your Lordships will readily see that those who work in the Palace of Westminster have a very personal interest in this matter. It is an interest which they should, and I sincerely hope that they will, take in all the other top level services which St. Thomas's could provide when the Westminster Hospital is closed.

Perhaps I may enlist the interest of the Minister so as to ensure that the agreement reached with her department and those authorities in 1988 is implemented in time to meet what by its very nature would be a crisis for those who have to use the service and in particular for the special cases to which the Question of the noble Lord, Lord Ennals, relates.

I was fascinated to hear of the excellent way in which Guy's Hospital had dealt with the terrible railway emergency. I was proud to feel that I share with the noble Lord, Lord McColl, membership of the united hospitals, as St. Thomas's and Guy's have been known for hundreds of years. I am perfectly aware that if St. Thomas's was faced at this moment with that enormous load of acute emergencies it would be able to deal with them. However, I very much doubt whether it could have done what the noble Lord, Lord McColl, stressed, namely, maintain the service for the area for which it is responsible. We are in that area now, or shall be when Westminster Hospital closes next year.

8.27 p.m.

Lord Strabolgi

My Lords, like other noble Lords I am very grateful to my noble friend Lord Ennals for initiating this debate through his Unstarred Question. The debate has centred on the threat to the hospitals and the emergency facilities if there should be a particularly serious emergency through terrorist action or a train crash. I should also like to make a plea for the ordinary casualty.

My noble friend described the zone which stretches from Oxford Street in the north to the Thames and from Park Lane across to Kingsway in the east. As he said, that zone contains the highest concentration of retail and office space in the world. The zone has comparatively few residents, and the number has been diminishing, although, as the noble Lord, Lord McColl, said, Mayfair is becoming increasingly residential again. However, there are many hotels and government offices. I should like to stress that by day the area fills up with hundreds of thousands of office and shop workers and visiting tourists. Those are the people for whom the hospitals will be responsible, as individuals, if they need immediate and early treatment.

Of all the great hospitals which the Victorians, with their wonderful vision and planning talents, placed around London, in this particular zone Westminster Hospital is the only one that remains. Apparently it is now to be closed.

We are told that in future cover is to be provided by the Hammersmith and Charing Cross Hospitals, which are respectively four and a half and three and a half miles away from Westminster. That is as the crow flies. In heavy traffic the journey takes at least half an hour and can take even longer during the rush hour. An ambulance may not take quite so long. A VIP going along with motorcycle outriders may be able to do it in a shorter time, but if you are an ordinary person having to go by taxi or by Underground—there are 12 stations on the route—it is a long journey.

I know that to my cost because I once had a bad nosebleed. It was not the kind of nosebleed that you can cure by putting a key down your back. I was sent from the Palace to the Westminster Hospital. At the hospital I was told, "We have closed our ear, throat and nose unit. You will have to go out to the Charing Cross Hospital". Contrary to what the noble Baroness appeared to think at one time when we had a Question on the matter, that hospital is no longer at Charing Cross but right out almost at Putney. The hospital provided a taxi for me. The first thing that the taxi driver said as I was holding my nose with the swabs that the hospital had provided—it was very helpful—was, "Have you got £5? That is what it will cost you?" Fortunately, I had five pounds. The journey took nearly 40 minutes. The taxi driver was very helpful. He had done the run many times before and he showed me which of the units to go to. I did not have to wait long. I found a good young surgeon who treated me and cauterised my nose. It was fixed up in a short time. However, if it had been a heart attack or a desperate emergency, it would have been a long journey.

As the noble Lord said, at the time of the terrorist bombing at Victoria Station last February, many of the seriously injured were taken to the Westminster for immediate treatment and assessment. What is to happen in future if there is a similar outrage or a bad train crash? I realise that the old St. Stephen's Hospital, which was a well-run hospital at the most north-easterly part of the Fulham Road, is being rebuilt and will be called the Westminster and Chelsea Hospital. It is only two miles from the centre and slightly nearer than the Hammersmith and new Charing Cross Hospitals, which, as I said, are almost at Putney. Perhaps the noble Baroness who is to reply will tell us when the Westminster and Chelsea Hospital will be finished and able to open. I understand from a senior and distinguished member of the medical profession that there are doubts about its future. That seems almost unbelievable, but with this Government you never know.

I hear too that St. Thomas's Hospital—that great hospital at which the noble Lord, Lord Richardson, has had such a distinguished career and about which he spoke so movingly, and the hospital to which I owe a great debt—is also under threat. That is incredible. Certainly, several wards and dozens of beds have been closed there and many staff, both specialist and ancillary, made redundant, to the Government's lasting shame. Can we be assured that hospitals such as St. Thomas's, which will have to deal with the emergencies once the Westminster has closed, will receive the funding necessary to deal with the extra workload? I hope that the noble Baroness will be able to reassure us on that point.

It appears that those decisions are being taken because of the high land values in the centre of London. This is not about patient care; it is all about real estate and property speculation. Populous areas, with their high land values, are effectively stripped of their local cover on grounds of cost and the so-called rationalisation of services. It appears that the situation has been brought about because the Riverside Health Authority is required to save £15 million each year from 1991 and its new plans must be self-financing within the district. Surely it would have been letter to have left St. Stephen's alone instead of spending £236 million on the new hospital, which may never open as, I understand, it is unlikely to be cost-effective, to use the current jargon, unless the Government provide more finance, and to have used some of the money to refurbish Westminster. Surely that would have been better than replacing St. Stephen's, which was an excellent hospital. I know from personal experience that it did not need rebuilding, with all the attendant delays. There would then have been some money left over to refurbish the Westminster and perhaps St. Stephen's.

The whole situation gives cause for grave concern. I hope that the noble Baroness, whose heart we know is in the right place, will be able to reassure the House that the Government will think again and save Westminster Hospital.

8.35 p m.

Lord Auckland

My Lords, in the words of one of the plays of the late J. B. Priestley, "We have been here before". However, I do not think that there need be any apologies for returning to the scene even though this Question, or a rather more limited Question on the Westminster Hospital—again asked by the noble Lord, Lord Ennals—came before your Lordships' House quite recently.

It is often said that London has too many teaching hospitals, and that may well be the case. When those of us in either House of Parliament talk about Westminster Hospital we may well be faced with the cynical comment, "Well, you would say that, wouldn't you?" because it is our hospital; but so what? It is our hospital. It is also a hospital which deals with an increasing number of people in the area.

I do not live in London. I live in Surrey, but for 25 years my father was chairman of a children's hospital in London which was part of the old St. George's Hospital. I was on the house committee of that children's hospital for several years and my father was on the house committee of St. George's when it was at Hyde Park Corner. As your Lordships know, I am President of the Friends of Epsom General Hospital, which falls outside the area of the debate.

Several years ago my gall bladder flared up and I just managed to get home to see my doctor. My noble friend Lord McColl made a pertinent point about gall bladder operations. I was in hospital for nine days because the problem was more serious than I had thought as my liver was infected. However, 20 years ago I would probably have been in hospital for three, four or five weeks for a gall bladder or appendicitis operation. It is therefore fair to say that many casualties can be treated much more quickly than they were 25 to 30 years ago. Your Lordships will accept the fact that there is probably less need for casualty departments at all the London teaching hospitals.

Like many of your Lordships, we have friends whose relatives or friends themselves worked at Westminster Hospital. One of my elder daughter's school friends was a nursing sister there for many years. Another friend of ours was a house doctor there for some years, so I have been round the hospital several times. There is a general belief that the hospital is in need of rebuilding, but I return to the question that has been raised in both Houses of Parliament and elsewhere: why can we not build on that site a new hospital with a full casualty department? I accept that St. Thomas's Hospital is nearby but I should like my noble friend the Minister to inform the House—I have not given her notice of this point, but it is a question that has been asked many times—about the casualty department arrangements at St. Thomas's Hospital.

Reference has been made to the terrorist attack at Victoria Station in which, mercifully, only one person was killed. A friend of mine was at the scene 10 minutes before the incident. Who knows what might have happened had the bomb gone off then?

I have travelled from Surrey to London, either on the Victoria or Waterloo line, almost every day for 37 years and until now I have never been involved in an accident. My mind goes back to a time before the Cannon Street and Clapham Junction disasters. There were two horrific accidents: one at Lewisham in the 1950s and one near Paddington—at Harrow, I think —where well over 100 people lost their lives. One speculates as to what would happen if an accident of that kind took place at the present time. Lewisham is not far from Guy's or St. Thomas's Hospital, and there may well be hospitals between Harrow and St. Mary's Hospital. It is not so much a question of terrorist attacks. If there is a major disaster—which we all hope will not happen—we have to be prepared for it. Let us say two trains collide between Wimbledon and Waterloo or between Streatham and Clapham Junction.

My noble friend gave an impressive description of what happened in the Cannon Street disaster. One pays a warm tribute to him and his team for the way they treated those casualties. Mention has been made of the Royal London Hospital. My younger daughter trained as a nurse at that hospital and I have some knowledge of it. A helicopter service was provided between the hospital and the scene of the accident, which I suspect saved a number of lives.

The main anxiety relates to the second part of the question posed by the noble Lord, Lord Ennals—namely, the planned reductions in hospital accident and emergency services. What are these planned reductions and what is their timetable? I believe that that question is worrying many people. It is not a party political matter. The closure of a number of casualty departments may well have been planned under all governments of all political parties. It is unnecessary to man casualty departments at every London hospital. On the other hand, the whole question of the provision of casualty departments extends well outside the London area. Anybody who lives near the M.25 in Surrey, as I do, knows that the accident and emergency provisions are not entirely adequate. We have to bear in mind not only Westminster Hospital and that area but all other areas of London.

Mention has been made of the distance between Westminster and the St. Stephen's and Charing Cross Hospitals, both of which I have visited. (I was at the opening ceremony of the new Charing Cross Hospital). Even if, in the event of a major accident in Pimlico or at Victoria Station, one had a bevy of police cars and traffic lights on red one would only have to have roadworks to make the difficulties of getting there very severe.

I wonder whether my noble friend can say what facilities there are at St. Thomas's Hospital. Obviously, if there were complete facilities at St. Thomas's Hospital it might be fair to say that casualty arrangements at Westminster were not entirely relevant. Although terrorist attacks seem to be on the wane at the moment we have to be prepared for a major accident. I believe that we owe a great duty to people like my noble friend and his colleagues to provide facilities for such awful contingencies.

8.46 p.m.

Baroness Masham of Ilton

My Lords, I should like to thank the noble Lord, Lord Ennals, for giving us the opportunity to bring before your Lordships some of our anxieties over the diminishing accident and emergency facilities in central London. I am sorry that this debate takes place this evening as I am missing a very interesting engagement at the Royal Society of Medicine which I had accepted, but this is a vital subject.

The noble Lords who are doctors have spoken of the merits of their individual hospitals, which is quite understandable. Maybe I should voice the feelings of the ordinary person. We are in the very heart of London sitting in the Mother of Parliaments discussing what to some people will be a life or death situation. Since the days of Guy Fawkes, Parliament has been a high-risk target. Last night when driving my noble kinsman home from an engagement in Piccadilly and nearing Marsham Street we saw policemen at nearly every corner, especially around Smith Square. My noble kinsman remarked on it. We have many police and security personnel around the Palace of Westminster. Could this be in case of a terrorist attack?

Not long ago there was a large hospital at Hyde Park Corner —St. George's Hospital—which had a busy casualty department. (I took my Red Cross nursing and first aid exams there.) Near Charing Cross Station was another hospital with a casualty department that dealt with many of the inner city problem cases needing emergency care. Both hospitals were moved out of central London. The moving of Charing Cross Hospital but the keeping of its name still causes confusion to many people trying to find that hospital as they look around the area by Charing Cross Station.

A friend of mine from North Yorkshire who visited London last week was told by a taxi driver that if Westminster Hospital with its accident and emergency department closed there would be only one A&E department left in the heart of London. He told her that that would be St. Thomas's Hospital which was on the wrong side of the river. People may argue that St. Thomas's is only a short distance across the bridge, but a river is a natural division and in history has always been so. In an emergency, such as a riot, a train crash, a tube station fire, a gas explosion or a terrorist attack—of which in recent years there have been many—a hospital like St. Thomas's needs back-up support. In recent incidents these hospitals have worked together sharing the casualties.

As crime rises, so does the fear of crime, leaving the most vulnerable centre of one of the important capitals in the world feeling insecure. Statistically, central London may not have as many residents as some other places but daily attracts hundreds of thousands of workers, users and visitors; and it attracts demonstrations, many held at weekends.

One of the advantages of the location of the Westminster Hospital is that most people know where Westminster is. The hospital is easy to get to and has easy access. It has a good reputation and is trusted by the people of inner city London who have to live with the fear of crime. It can be identified by foreigners and visitors to London. There is a car park nearby, and public transport is available.

There is a team of Ministers at the Health Department whose members seem to be quite young and very healthy. The noble Baroness, Lady Hooper, told me that she has been lucky in that she has never been a patient in hospital. I hope that she will continue to enjoy good health. But the experience of illness makes people understand and be more sensitive to the needs of the sick. The Ministers have a good deal of responsibility. They should not wash their hands of the situation and they must face the fact that central London is unique. It is a special case.

The City of Westminster has an enormous number of homeless people as well as alcoholics and drug addicts. It has the largest number of people with the HIV infection. There are caring, voluntary groups working round Westminster Cathedral who help those unfortunates. Many of the homeless people become acutely ill and, not having a GP, they are taken to the A&E department of the Westminster Hospital. The Westminster Hospital has experience of such emergencies which are more pertinent to this part of London than to any other. Perhaps I may ask the question: how good is our medical care of the homeless? If the Westminster Hospital closes, it will raise just one more dilemma for the voluntary agencies which are trying to cope with this problem. That is very relevant to the Question asked tonight and should be included as one of the "other emergencies".

Those difficult and tragic cases are not popular with hospitals. These people who have numerous infections and problem life-styles drift to the capital cities. They do not feature as a residential statistic. I read in the paper that the City of Westminster wants to deport them lo other parts of the country. If that is done, others will take their place. There is a problem of hundreds of Italians, Spanish and South Americans who have come to London and who have the HIV infection because of drug abuse. With the first attack of pneumonia, they become critically ill emergencies. If central London shuts its doors and services to such difficult cases, the dilemma will grow and there will be endless problems. Who will the public blame? It will not be the health authority but Parliament.

We who speak tonight know that our words will be recorded, in the Official Report. Central London needs to feel secure. The Government's health service shake-up may have some benefits but many members of the public are saying that enough is enough.

Having had my life saved in an accident and emergency department, I know the value of a quick, efficient service with skilled consultant input. In the past I have always felt that it was wrong to have some of the most junior doctors manning A&E departments. The situation is improving. If there are serious accidents, skilled A&E teams should be available and they should have quick egress from their hospital and easy access to the site of a catastrophe. A&E departments have been chronically underfunded and cannot do all that they would like to do at the present time. To take but one example: Westminster Hospital was built to take 25,000 patients a year. It now takes around 40,000 new patients every year.

One cannot have an A&E department without having the back up services and beds in which to put the patients. I have heard said that the A&E department of St. Thomas's Hospital will be extended. But where are the beds which will take the critically ill patients? St. Thomas's belongs to another health authority. Who pays the bills of the patients who are brought in suffering from a stroke or coronary thrombosis or stab wounds from a pub brawl in Piccadilly, or other disasters? Who pays for the ambulance service? Is it the district in which the person is injured or is it the receiving district? What happens if the wards are closed because of underfunding or staff shortage?

One Member of your Lordships' House thought that the new hospital, which has no parking facilities and no standby space for ambulances, was just down the road. She was getting muddled up with the new private hospital. The new Royal Chelsea and Westminster Hospital will, yet again, confuse the public. Why not call it the Fulham and Chelsea Hospital? That name makes where it is much clearer to the public. It also shows the public that Westminster will be without a hospital.

Many of the doctors were told that the new hospital would be the most modern in London; but they seem to have been conned. I have been told that they were promised the most up-to-date digital imaging system of filming X-rays. Apparently that has had to be shelved through lack of money. I have met many worried people—elderly people from the housing estate in Page Street. How are the little old ladies who live alone going to manage to travel half-way across London when they feel desperately ill? They will not be able to afford the £5 that the noble Lord, Lord Strabolgi, had. I wonder what the traffic division of Scotland Yard will say about the parking facilities at the new hospital site in Fulham Road if there is an attack on Westminster.

Every medical emergency that has serious results can mean a family tragedy. If one has chest pains, the stress of being stuck in a traffic jam, be it in an ambulance or a private car, will make the condition worse. I hope that not too many obituaries will read: "He died on the way to hospital".

I hope that the Minister will be able to give assurances tonight which will make people feel more secure, less vulnerable and less confused than they do now.

8.58 p.m.

The Viscount of Falkland

My Lords, on my own behalf and also on behalf of my noble friend Lady Robson of Kiddington, I too am grateful to the noble Lord, Lord Ennals, for introducing this debate. In the normal course of events she would have spoken in the debate. I have been brought in as a long stop because she has been unavoidably detained elsewhere. As often happens in your Lordships' House when one comes fairly late in the evening to a debate in which one does not expect to figure, it turns out to be fascinating. No doubt I am the least qualified of noble Lords to speak on this subject but I have been well, if hastily, briefed by my noble friend.

These Benches would not want to become involved in any party political angle on the subject of the changes that will inevitably happen with accident and emergency departments. It is inevitable because it seems that the many drawbacks in the present situation have to be dealt with. The noble Lord, Lord McColl, gave us a number of reasons for that and I was most impressed by his speech. The question of how those changes take place and how they affect patients concerns us all on these Benches.

Although I do not have personal experience, happily, I have had friends and relatives involved with accident and emergency departments. The care has always been excellent, as was pointed out by the noble Lord, Lord McColl. That is so not only in major and tragic events such as the Cannon Street and Victoria explosions but in large traffic accidents and so on. In such situations I have heard very good reports of the attention that people in London have received.

It follows that there must be great anxiety when a major hospital such as Westminster is scheduled to close. I enjoin with all that has been said by noble Lords on that aspect and on the problems that we face in the intervening period until we obtain a proper network of hospitals and, equally important, the transport which inevitably needs to go with that. I agree absolutely over the problems raised by many noble Lords, in particular by the noble Lord, Lord Strabolgi. They include the traffic situation in London and the time that it takes to get people from one place to another, even with a blue light flashing and with expert drivers.

On occasions I have taken people to accident and emergency departments. Those departments appear to look after people with various problems. Normally an accident and emergency department treats a wide range of patients apart from those brought in after a tragic accident at, for example, a railway station, as has been referred to. They include people suffering as a result of household accidents and minor traffic accidents, people who have had minor as well as major heart attacks, people with broken arms, and so forth.

On occasions when I have been to such departments I have wondered whether a number of the patients should be there. The word "inappropriate" was used in one of the papers that I read. It is a good word to refer to people who attend through eccentricity, because they find it more convenient as they do not have regular access to health care or because they are homeless. After all, there are about 75,000 homeless people in London. It may include those who suffer from alcohol problems. The noble Lord, Lord Ennals, knows that I have had something to do with that problem. Such people find their way to these departments. In particular at weekends, when social services are not available in the way that they are during the week, the elderly and mentally ill are also to be found in those departments.

Perhaps the noble Baroness will answer this question when she replies. If the move to new and more efficient modern accident and emergency departments takes place, what will happen to those people who are to be found every night in such departments? If we were to visit a department tonight we should find them there. Will the future of the accident and emergency services be considered as part of the provision of health services overall? That seems the only way to deal with the issue.

The centralising trend for accident and emergency departments appears to follow what occurs in many other countries. I believe that in some other countries such centralisation has worked well. It has reduced the number of deaths in many cases because of increased efficiency. However, we are still faced with the particular problems of London which have been referred to by noble Lords.

I have heard the centres referred to as regional trauma centres. If they are to be better equipped and to offer a much more professional service, how will they be supported by other services such as ambulances? The staffing of the departments raises a number of questions. One of the most important points raised by the noble Lord, Lord Ennals, concerned a strategic planning authority for London. Such a body does not exist, whether it be for dogs, holes in the roads or any other issue. It certainly does not exist for health services.

There is a danger in making decisions about such changes when an overall picture of the needs of an area is not known. Many noble Lords have referred to the problems of London. The dangers of terrorism prompted the noble Lord's Question. There are also enormous numbers of homeless people. There is a high concentration of people with drug and alcohol problems. There is the problem of the mentally ill sleeping rough and the dangers which they face. Vast movements of people aggravate the situation.

Other noble Lords have referred to bed closures. I have received two letters which I read before speaking in this debate. It is distressing if, due to a shortage of beds in accident and emergency departments, people who require serious medical attention have to wait on trolleys for hours. It is extremely disturbing not only to the patients but to the relatives who are anxious for them to be treated.

I do not point the way forward as strongly as the noble Lord, Lord Strablolgi. However, I believe that it must be clinical rather than economic. The noble Lord referred to real estate being a priority rather than patient care. That puts it rather more mildly than my colleagues have done. However, I take his point. Staffing levels are another problem which has not been mentioned. The ratio of qualified and unqualified staff in such centres needs seriously to be addressed. When one calculates the number of staff required, one must consider the needs of the patients rather than the number of bodies going through the system.

I wish to raise one matter which is not in my brief but which has worried me for some time. Recently I was talking to a nurse who had been attacked in an accident and emergency department of a hospital. Violence against staff working in such departments has reached an intolerable level. How is it possible to move forward to an age of efficiency and professionalism if staff are living in perpetual fear of being attacked by someone who is mentally unstable, under the influence of drink or for any other reason? The issue must be addressed and I wonder whether the Minister has any comments to make this evening. Some of the stories that I have heard about attacks which take place on a regular basis are horrifying and complicate the situation unnecessarily.

The need for comprehensive planning is a vital aspect of the issue. London should be treated as a single entity and not piecemeal. I look forward to hearing the Minister's comments and hope that she will give the House an optimistic view.

9.9 p.m.

Baroness Hooper

My Lords, I thank all noble Lords who have participated in the debate. I agree with the noble Viscount, Lord Falkland, that the last thing we wish to do is to make a political football of the National Health Service, and in particular of the accident and emergency services. I wish to extend our heartfelt thanks to all those who work for the accident and emergency services and who dealt with the casualties resulting from the tragic incidents about which we have been reminded this evening. We cannot praise them too highly.

I must dispute the contention put forward by the noble Lord, Lord Ennals, that accident and emergency services are being reduced. That is not the case. The examples that he quoted demonstrate plans to re-provide existing services but in more suitable surroundings. He may dispute the location of some emergency services, as have other noble Lords, but he is being unnecessarily alarmist in suggesting that the level of these services has been reduced. Furthermore, Westminster Hospital—the local—is not being closed down but is being relocated only some four miles away. Therefore I take the opportunity to reassure your Lordships and members of the wider public who have an interest by showing that the Government have a com prehensive plan for dealing with major incidents in London.

We recognise all too well the dangers from terrorist activities and the need to react to crises and major incidents. Each district health authority must have a comprehensive set of plans for dealing with major incidents. All regions must maintain a list of hospitals with A&E departments suitable to receive casualties on a 24-hour basis. The lists set out the hospitals' capacity to deal with various types and different degrees of severity of casualty and their ability to send medical and nursing teams to the site of an incident if required. The list is held by the London Ambulance Service, which nominates one or more hospitals for standby.

The hospitals designated to deal with emergencies must draw up detailed plans, including arrangements for ensuring that teams of staff are available to receive casualties. They must also ensure that beds are available for patients who need to be admitted and that there are arrangements for keeping relatives and the media informed. Guidance also lays down that any major incident is followed by a debriefing session in order to examine how the incident was handled and what lessons can be learnt. It was admitted during the course of the debate that the reaction to recent incidents has been extremely good. To that extent the system and the arrangements that are in place have proved themselves.

As regards the City of Westminster there are and will remain no fewer than seven major hospitals within easy travelling distance—I realise that is a disputable suggestion—which are designated to treat casualties in an emergency. They include all the hospitals mentioned this evening; they are Westminster Hospital at its present and future site, and Hammersmith, St. Mary's, St. Thomas's, Guy's and University College hospitals. No other part of the country is so well served.

I sympathised with the noble Lord, Lord Strabolgi, when he told the House about his nose-bleed and his journey to Charing Cross Hospital. However, I wondered why he did not go across the river to St. Thomas's Hospital—

Lord Strabolgi

My Lords, I am sorry to interrupt the noble Baroness but I was sent there by the Westminster Hospital.

Baroness Hooper

My Lords, I wonder why the noble Lord himself did not suggest that he would prefer to go somewhere closer.

I take the opportunity to refer to something raised by the noble Lord, Lord Ennals, who mentioned that I had previously referred to accident and emergency facilities at the Middlesex Hospital. He is right to say that the accident and emergency department at the Middlesex Hospital has been closed. However, that hospital is linked with the nearby University College Hospital, which has accident and emergency facilities.

Existing arrangements are impressive but it would be foolish to pretend that no improvement is possible or that services need not adapt as medical techniques change. One important subject of debate in medical circles is whether more small facilities should be provided or whether services should be concentrated in larger centres. In some areas health authorities maintain the so-called minor casualty units for the walking wounded, where less seriously injured people can refer themselves for treatment. Those units have a role to play in areas where it is a considerable distance to the nearest large accident and emergency department. As my noble friend Lord McColl pointed out, the trend over recent years has been to concentrate accident and emergency services in district general hospitals, with the back-up of sophisticated diagnostic techniques and treatment facilities, and where senior medical staff across a range of specialties can provide additional advice in cases where a patient has suffered multiple injuries.

Research studies published by the Royal College of Surgeons show that significant improvement in the chances of survival for major trauma patients can be achieved in larger departments. I am sure that the noble Baroness, Lady Masham, recognises that. The Royal College recommended the greater use of special trauma centres. That proposal is currently being evaluated at a new trauma centre in Stoke on Trent.

The noble Baroness, Lady Masham, asked who would pay for the emergency admissions to hospital. I can reassure her that it is the health authority where the patient normally resides which will be responsible for meeting the cost of treatment and systems are in place for carrying out the necessary arrangements to ensure that.

The noble Lord, Lord Ennals, and others referred to the London Ambulance Service, which is the major means of transporting casualties. That service decides which hospital should be designated for taking casualties and which others should be on standby. It can also call on the assistance of the police to clear routes for ambulances. The effectiveness of all that was proved in the recent major incidents.

The London Ambulance Service carries half a million emergency patients a year. Every one of them and their families have good reason to be grateful for the service's effectiveness. The four Thames health regions have a centralised contract, which means that there is a unified emergency provision across the whole of London. The emphasis is on high quality emergency care at short notice.

Again, we are seeking to improve the London Ambulance Service. Some of the most exciting developments in that service relate to emergency ambulance provision. We are investing in improving the command and control centre of the Ambulance Service. We hope that that will result in improved response times. We are providing cardiac defibrillators in every ambulance and staff training so that they can be used by the end of July this year. We are also providing training for ambulance staff to ensure that we have an extra 144 paramedical staff in emergency ambulances each year. We are looking at the possibilities on the basis of the helicopter emergency medical service which is currently operating from the Royal London Hospital.

The second main point which emerged in the debate and on which I should like to concentrate is how the emergency services coped with recent incidents. As I have already said, we are full of admiration and gratitude for the swift and splendid response by the staff and everyone else involved in both the Cannon Street rail crash and the Victoria bomb incident. From what I have said, it is evident that we fully recognise the valuable work that is being done.

The third point I wanted to make to reassure your Lordships is that planned service changes in London will not reduce the capacity to respond effectively to major incidents. As has been stated, we have debated the replacement of the Westminster Hospital by the new Westminster and Chelsea Hospital. I repeat that before the scheme was approved careful consideration was given to the implications for services including the emergency services. The London Ambulance Service was consulted and it agreed the proposed changes. The project was subject to full consultation and debate. The decision was reached after very careful consideration of all the views expressed.

Lord Ennals

My Lords, does the Minister agree that most of those who were consulted stated their opposition? The consultation was wide, short and conclusive. It was a conclusive no—that this was not a good thing either for the residents or for most of the professions involved. Certainly the Westminster Council opposed it from the very beginning.

Baroness Hooper

My Lords, I repeat that the Government gave careful consideration to all the views expressed. It was considered necessary to relocate the Westminster Hospital. I believe that there is fairly wide agreement that the facilities available on the present site need replacing. Specific questions were raised about the new Westminster and Chelsea teaching hospital. There was particular reference to the increased costs. The North-West Thames Health Authority originally planned to finance the whole cost of the project from land sales achieved from the reconfiguration of the hospital services. However, the region faced considerable difficulties outside its control because of the downturn in land values and sales. As a result, the capital programme in the region is being reviewed.

Nevertheless, I am pleased to be able to tell noble Lords that it is still planned that the hospital will open in April 1993. That will coincide with the new contracting year. The services will be greatly improved when they are relocated in one modern district general hospital with all back-up and support services available. I point out to the noble Baroness, Lady Masham, that they will include adequate parking facilities. The new 650-bed hospital will provide a modern, up-to-date environment for health care into the 21st century. That will also help staff recruitment and it will enable the health authority to maximise the use of scarce qualified staff.

In addition, the new hospital will have an accident and emergency department capable of dealing with up to 60,000 cases a year. I repeat that we must not forget St. Thomas's Hospital across the river to which the noble Lord, Lord Richardson, also referred. It can deal with over 75,000 attenders a year. I can assure the noble Lord, Lord Strabolgi, that there are no plans to close that hospital. I am sure that a hospital with such a great reputation as that held by St. Thomas's will be attractive to district health authorities and GPs and they will send their patients there.

The noble Lord, Lord Richardson, raised the specific question about an agreement between North-West and South-East Thames Health Authorities to give more money to St. Thomas's Hospital to deal with more patients because of the construction of the new Westminster and Chelsea Hospital. I understand that additional revenue and capital funding has been transferred from the North-West to the South-East Thames Health Authority. I believe that the sum is over £200,000. However, I am happy to assure the noble Lord that I shall check whether there is any continuing disagreement about the level of funding to be transferred. Perhaps I may return to him on that matter. I hope that I have dealt with most of the points concerning those two hospitals. We heard from my noble friend Lord McColl about the position at Guy's and Lewisham.

I turn now to the issue of the general provision for London. The noble Lord, Lord Ennals, referred to the recent call by Sir Alan Greengross for a London health authority. We consider issues such as this on a regular basis. We are nevertheless not convinced that a single authority is the answer to London's problems. London cannot be looked at in isolation from the shire counties, which currently depend on London hospitals for many services. But the NHS Management Executive fully recognises the need for the four Thames regions to work closely together to ensure that services for London are properly co-ordinated, and there are systems in place to ensure that.

The noble Baroness, Lady Masham, and my noble friend Lord Auckland said that London is a very special case. No other part of the country is as well served as London. The noble Baroness also referred to the plight of the homeless. Although I think that that is a little wide of the Unstarred Question, I refer her to the initiatives of my honourable friend Sir George Young on that front.

There was a suggestion that London has lost a good many beds. The population of central London has fallen substantially, particularly relative to surrounding areas, since many of its hospitals were originally built. There is a need to ensure that more people can be treated locally if that is what they prefer; and that is what they seem to prefer. This point was referred to by my noble friend Lord McColl. Bed numbers have been falling steadily nationally for some years because of shorter stays, new methods of treatment, more use of day surgery and so on. Although the fall in bed numbers in London has been faster than elsewhere, this reflects the policy of successive governments to distribute resources more fairly throughout the country and to allow more people to be treated locally since that is what they wish.

We have received a report prepared by York University as a study of London health costs. It gives a considerable amount of detailed technical analysis. We shall wish to study it carefully and discuss any implications with the Thames regions. I am glad to say that the report did not suggest that we should try to prevent change in London. We shall, however, be looking to the NHS Management Executive and the regions to ensure that any changes which are necessary, and are shown to be so needed, are properly managed.

While I understand the anxieties that have been expressed I hope that I have been able to demonstrate that we have in hand comprehensive plans for dealing with major incidents, that the capital's hospitals have put their plans into action and have shown unquestionably that they are able to deal with these tragic incidents, and, finally, that the planned changes, particularly the opening of the new Westminster and Chelsea Hospital, will enhance the service. It is important to remember that we have a health service to be valued, with staff who are highly trained and committed to their tasks and who provide an excellent service, not least here in central London.