Health Care in London: Tomlinson Report

HL Deb 02 December 1992 vol 540 cc1345-416

3.14 p.m.

Lord Annan rose to call attention to the Tomlinson Report and to the case for the modernisation and development of the facilities for general practitioners in London and for the reorganisation of teaching and research in the inner London hospitals; and to move for Papers.

The noble Lord said: My Lords, the Motion I am moving should be as much in the name of my noble friend Lord Hunter of Newington as in my name, since he and others who will speak this afternoon are far more qualified to move it. The only melancholy qualification which I have is that from my experience in the University of London, with its then 14 medical schools and 11 medical institutions, I know how prodigiously difficult it is to persuade the consultants and practitioners in teaching hospitals to adopt the conclusions of any report.

The nub of the Tomlinson Report is this. London's historic teaching hospitals are mostly in the centre of London. Unfortunately, too few people live there. Those hospitals are all expensive and the money spent on them is needed to relieve London's inadequate and often squalid primary health care. There are numbers of consulting rooms without basin, lavatory or couch on which to examine patients. London is full of the homeless, refugees and very poor people, speaking 50 languages. The turnover in population is high. In some wards 15 per cent. are not registered with a general practitioner. London needs local health centres because a higher proportion of general practitioners than elsewhere are over 65 or work single-handed. The report says that it will cost £140 million to bring primary health care up to standard.

Where is the money to come from? Sir Bernard declares that fewer beds will be needed in central London, partly because fewer outpatients from the suburbs are likely to be treated as the district health authorities will find it cheaper under the new system of purchasing services to buy those services locally rather than in the great teaching hospitals; and also partly because techniques in medical care are changing and patients are hospitalised for shorter periods.

Therefore Sir Bernard recommends that 2,500 beds should be closed, the number of medical schools reduced to four and the number of medical students reduced by 150, to between 500 and 600. Furthermore, he recommends that the students should be taught more in community settings with general practitioners and in the peripheral hospitals which serve more densely populated areas. Even more ominous for the teaching hospitals is his recommendation that the special increment for teaching and research (SIFTR) should be shared with those peripheral hospitals. Sir Bernard hopes that the money saved by the rationalisation of the teaching hospitals and the sale of their sites will be available for improving primary care and for restructuring the medical schools.

This is the third time in 25 years that a report has been made recommending that savings could be made by merging London's teaching hospitals. The 1968 Royal Commission of the noble Lord, Lord Todd, reported in those heady days of great expenditure on universities. He envisaged the purchase of sites and the erection of gleaming buildings running into many millions of pounds. They were to be the wedding gifts to the brides and grooms he had proposed should marry. But when the dowries were not forthcoming it was a case of "the marriage arranged will not now take place".

Then came the noble Lord, Lord Flowers, and his working party in 1980. They were far more successful. The marriage between the Westminster and Charing Cross was actually consummated and the Middlesex and University College Hospital formed joint departments. What is more, St. Mary's looked across Hyde Park and fell into the arms of Imperial College. But Guy's and St. Thomas's, though they went to the altar, did not cohabit. Bart's, though it was compelled to merge its pre-clinical medical school with Queen Mary's Westfield, did not unite its clinical departments with those of the Royal London. Once again the Royal Free declined all offers of marriage and remained a spinster.

Why did those two initiatives fail? The first reason can be summed up in the word "turf". Consultants refuse to surrender what they call "my beds" and therefore refuse to merge their department with that in another hospital. In paragraphs 148 and 149 of the report Sir Bernard gives examples of shameful duplication of services and specialties that continue because consultants continue to cling to their turf.

The second reason flows from the first. Whitehall tried to make the tail wag the dog. The Department of Health was always hoping that the University of London would solve its problem for it, because if some medical schools could be closed, the hospitals could be closed. The only place where that was on the cards was Westminster. So long as a hospital was not under direct financial threat, why should a medical school sacrifice itself? But under Tomlinson the main onus for success or failure will rest on the Department of Health.

The only way economies can ever be made in London medicine is by applying financial sanctions. In 1970 I implored the principal and the court of the University of London to produce a financial shotgun to induce the medical schools to marry. They would not do so. Today it is equally vain to hope that the University of London will do so. The university is saddled with a constitution which in my judgment is incapable of taking unpopular and contentious decisions. Indeed, the University of London no longer has the power to do so because the big multi-faculty schools are now financially independent. The Universities Funding Council is therefore now making separate deals with the four main multi-faculty schools under which the medical schools are to be grouped. As a result, the vice-chancellor and Sir Colin Dollery, who are trying to co-ordinate policy, find that medical schools tell them one thing and without consultation they and their parent multi-faculty school tell the Universities Funding Council or the Department of Health something quite different.

But even more alarming to me is the attitude of the Universities Funding Council. Mr. Graham Davies, so I understand, has reassured medical schools that he will not employ financial pressures to compel them to amalgamate and save resources. So on the academic side there will be little pressure to change.

I do not want to be unfair. There has been a change of heart in the medical schools. I do not doubt that Guy's and Thomas's are now willing to merge with King's and even accept that one or other site will have to be vacated. As for the smaller specialist hospitals, St. Mark's, for instance, goes all the way with the report in its recommendation—a very sensible one it is too—that St. Mark's should move to Northwick Park and separate from Bart's.

The pressure to change, the report argues, will come from the Department of Health provided that the Secretary of State is firm. The pressure—so Tomlinson thinks—is inevitable because the new policy in the NHS of forcing district health authorities to purchase services in the cheapest market has opened a gap between the purchaser and the teaching hospitals that until now provided those services. The gap is now £70 million to £80 million and the deficit in those hospitals is forecast to rise soon to £130 million. So the report assumes that at last the shy spinsters, such as St. Bartholomew's and the Royal Free, will recognise that they must embrace the suitor that has been waiting for them for the past 25 years.

That brings me to my main criticism of the report. For a report that is financially driven, it has a negligible amount of financial reasoning. The report's main argument is that the savings made by amalgamating teaching hospitals will then be available to improve primary care. Can naivety go further? Whoever heard of the Treasury agreeing to a swap of that kind? Again, does anyone believe that British Rail is financially in a position to buy poor quality buildings from St. Mary's?

Indeed, will there be any savings visible? I hope that the Secretary of State will not urge the move of the Royal Marsden and the Royal Brompton into Charing Cross. It would cost anything between £50 million and £80 million. I hope, however, that she will compel them to merge financially and administratively and to merge their pathology departments. Savings of that kind can be made. Some specialist hospitals in central London could sell their sites, but not until the big teaching hospital sites have been rebuilt. The trouble about rationalisation—it is always the same —is that it nearly always requires more expenditure today to bring about real savings tomorrow.

The University of London accepts that primary health care must come first and that the decisions on teaching hospitals will follow. But the university naturally says that very large sums will be needed to bring about the change—for redundancy, for vast alterations to premises and, above all, for the preservation of London as the national centre for clinical research. Some of these claims are valid. If King's College is to teach the pre-clinical students of the combined schools of King's, Guy's and Thomas's, those pre-clinical departments must have new premises on the St. Thomas's or the Guy's site. At UCH there is the vacant Odeon site, as it is called. Build on that, refurbish the remaining buildings on that site, and most of the Middlesex site could then be sold. The cruciform building, listed as an historic object, could be left closed until later; then it could be refurbished to bring in institutes and beds for child health, ear, nose and throat, neurology and ophthalmology.

I hope that the noble Baroness will be able to confirm that like a wise squirrel she has been hiding a store of funds to start some of these schemes. It would be disastrous if after all this work nothing could be done to keep the momentum going. I hope too that the noble Baroness will give some indication about the future of the Bart's site, which contains historic and listed buildings. If it must merge, could not that great institution house specialist centres and become a polyclinic serving out-patients from the commuters to the City of London?

There has to be some change in London medicine. But at the same time the report contains some other contentious assumptions with which I hope the noble Baroness will deal. Is health care in London so much more expensive than elsewhere? Noble Lords from north of the Border will not, I hope, mind me mentioning that the cost of the NHS in Scotland is 30 per cent. higher than in England and Wales. In London 14.7 per cent. of patients, Tomlinson admits, wait more than a year for a bed. In fact, London has only 4 per cent. more beds than the national average. The report admits that the special needs of London are 5 per cent. above the average. Does that not balance the account?

I do not neglect the anguish which rationalisations of this kind cause. There are more lawyers than doctors in this House. I ask them: how would they react were it proposed that the Inner and Middle Temples should merge, that the Middle Temples be demolished, the site sold and a quarter of the barristers and their pupils sent on to the northern circuit? We are discussing today an issue which rouses the strongest emotions. I could feel the noble Lord, Lord Mellish, breathing down my neck—I cannot feel it any longer, because he has left his place—every time I mentioned the word Guy's. Whatever I say does not diminish my sympathy for those whose professional status and livelihood are threatened. Doctors are fanatically loyal to their hospitals as are officers to their regiments. But there is this difference: officers are trained to obey orders from above.

Loyalty to hospitals is not confined to the medical profession. We too are fanatically loyal to the hospital of our choice. Some of the worst mistakes in medical planning can be laid at the door of Members here and in another place. Was it not loyalty to the Westminster Hospital that led to the erection of the vast new hospital on the Fulham Road which no one, except the inhabitants of Fulham, now wants and which has led Tomlinson to recommend that Charing Cross Hospital only a short distance away should be closed? I implore your Lordships—those who have come here to make a plea that their favourite hospital should not be touched —to put forward a practical alternative.

I am trying to speak for less than my permitted time in order to give my noble friend Lord Hunter an additional few minutes. However, I wish to add one further point. I hope that an argument that I have heard expressed on several occasions will not be pressed. It is that there must be an accident and emergency centre to meet cases of cardiac arrest, cerebral thrombosis or other grave injuries occurring in the Westminster and Whitehall area. It would be cheaper and more effective to have a small paramedic unit in or near the Palace of Westminster than to keep a whole hospital in being. The public accepts that outside London a 30-minute ambulance journey to hospital is par for the course. We are still within 15 minutes by ambulance of UCH or the new Westminster and Chelsea Hospital. On that sombre note, my Lords, I beg to move for Papers.

3.32 p.m.

Lord Desai

My Lords, we are all grateful to the noble Lord, Lord Annan, for giving us the opportunity to debate this issue. Its importance is indicated by the number of noble Lords who have put down their names to speak. Indeed, we are looking forward to hearing some splendid maiden speeches. In the short time at my disposal I shall concentrate on some general principles rather than talk about particular hospitals or areas.

London has long-standing problems which are outlined in the Tomlinson Report. It lists previous reports which have also pointed out that London's two major problems are an inadequate provision of primary health care and an over-concentration of hospitals in inner city areas. If those problems have existed for so long—that is, before and during the NHS—why have they suddenly become rather urgent?

In some ways the arrangements have stood the market test. The health status of people in London, especially in the deprived inner city areas, is no worse —indeed, it is better—than that of people in deprived areas elsewhere. That is shown by the King's Fund Report. The problems have become urgent not because they are new. The new development is the changed mode of financing. The Tomlinson Report and the King's Fund Report have not addressed themselves to the real radical question of whether, if one has an internal quasi market, the present system is the best system for creating that. At the root of some of the problems which are today urgent for London but which tomorrow will affect every large urban area in the country is the system of financing; the method of providing the money. Until we examine that issue we shall no doubt reach the wrong conclusions. Those conclusions may be persuasive in the light of the given financing arrangements, but I believe that they must questioned.

London is not over-bedded nor is it overtly unhealthy. However, we are told that health care in London is expensive. As regards the private market, London's theatres and restaurants are more expensive than those outside. Indeed, anything one does in London costs more than anywhere else. The private market, whose virtues are extolled by Members opposite, has a nice logic; it sets different prices for different commodities provided in different areas. But that logic is not available to a bureaucratic quasi market, which sets the same price. The problem is that having cut ourselves off from the universal entitlement in the NHS so that people do not have to worry about prices except in an overall budget context, we now have to set prices. Setting one price is inadequate; one has to set a separate price for different districts and areas and for people differing in age, health, gender and so on. That is what the market does but we have not done that. The result is the strange belief that London is too expensive and something must be done about its hospitals. Let us remember that through the 1980s many small hospitals in London were closed down or merged. Now one of the conclusions is that London needs more small hospitals. Therefore, having closed down several small hospitals we now need more new small ones. We must check against hasty reform.

Furthermore, in pricing services and making capitation grants we have, first, adopted a simple mode and, secondly, we have forgotten that teaching hospitals need patients as a resource. They do not represent only a cost; they are a resource for future research and an asset. That is another principle that is hard to remember. My time is running out. All I can say is that radical reasoning is required. We must think again and think carefully about re-examining not only London's hospitals but the financing of health care throughout the country.

3.37 p.m.

Lord Winstanley

My Lords, I have only six minutes and so I too shall endeavour to dismiss the universe in a few easy phrases. I thank the noble Lord, Lord Annan. for giving us the first bite at a large cherry. Perhaps it would he appropriate to describe the subject as a whole hunch of cherries. I am certain that your Lordships will need many debates on the subject during which we shall have more than six minutes to discuss individual topics. There are many issues to be discussed in great detail before they are finally resolved and I am sure that by one means or another—whether as a result of the Government or others providing time—we shall have many debates on the subject. I say to the noble Lord, Lord Ennals, who has already had his six minutes to discuss the matter, but in another way, that he will have many more opportunities in the future.

I also congratulate the noble Lord, Lord Annan, on wording his Motion in such a way as to invite us to study this complicated subject in a logical fashion. He has asked us to look first at the needs of domiciliary and community care in London. I am sure that he was right in doing so. I also thank Sir Bernard Tomlinson for his report, which was published speedily. It appears to be a little short on evidence but has much to commend it in certain of its conclusions. I welcome the fact that the report is the first I have seen which begins with a summary. The summary is very interesting. It states: Primary and community health services are comparatively underdeveloped in London. Resources need to be diverted from the hospital sector into these services in order to bring standards up to those found elsewhere, and to enable the rationalisation of hospital services in inner London. In particular, additional funds need to be made available for raising the standard of GP premises in inner London. Greater flexibility needs to be introduced into the General Medical Services so that within designated 'primary care development zones', FHSAs will he able more effectively to secure strategic health objectives". At the very beginning of the report Sir Bernard directs us to what is absolutely crucial.

In my mind there is no question but that there is a great deal wrong with community and domiciliary care and family health services in London. In March 1990, 60,000 people in the city were in temporary accommodation or sleeping rough. There are now more than 26,000 homeless people in the capital. Those people have almost no access to family health services, but they should have such access.

Some noble Lords may remember that a report published some time ago said that there should be an experiment with salaried doctors; that there should be full-time salaried GPs. The experiment was never conducted. The Labour Party, which liked the idea of a salaried service, realised that that was only possible in a system of health centre practices. From a capital investment point of view it would have been utterly impossible to establish health centre practices in every part of Britain. Therefore, no attempt at that experiment was ever conducted.

Now we have an example. The Government have appointed salaried dentists in certain areas to supply National Health Service dental treatment in places where it is not otherwise available. I suggest that there should be an experiment with salaried GPs in certain areas to ensure that homeless people or those in bed and breakfast accommodation at least have an opportunity of access to GP services.

Much else is wrong with community services in London. Almost half—that is, 46 per cent.—of general practitioner services in London fall below the Government's minimum standard. The capital has twice the proportion of singlehanded GPs and three times the national average who are over retirement age. Not only must GP practices in London be brought up to a decent standard but they must be designed in an appropriate way for the use of the elderly, disabled and those chronically ill who are no longer to receive hospital treatment and hospital care. That is absolutely vital.

I come from Manchester. I qualified in medicine at Manchester University. I then worked in hospitals in Manchester. It would be an impertinence for me to start talking about London hospitals and I should not dream of doing so. The situation in London hospitals has developed historically. Able and talented people have inevitably moved to London and therefore there have been centres of excellence in London hospitals. But we have had them elsewhere—in Newcastle, Liverpool and Manchester. In London they were concentrated.

The Government should begin on the first task; namely, to improve community and domiciliary care in London. They should realise that that will cost money but the money is there to be obtained later when they move to the second part of the exercise. They will obtain the money from the re-organisation of the hospital teaching and research services in hospitals in London. I hope that the Government will proceed in that way.

I look forward to hearing the maiden speeches today, in particular that of the noble Lord, Lord Hayhoe. I believe that he escaped from office before the review of the National Health Service by the noble Baroness, Lady Thatcher, was written. I do not know. Perhaps he was responsible for it.

3.44 p.m.

Lord Hayhoe

My Lords, first, I must say how grateful I am for the warm and friendly welcome that I have received from noble Lords in all parts of the House. I thank also the Clerk of the Parliaments, Black Rod and officers and staff of the House for their help and advice.

The contrast in coming here from another place is quite distinct, if not as sharp, as that noted by Mrs Patrick Campbell on her marriage when she spoke of exchanging "the hurly burly of the chaise-longue" for "the deep, deep peace of the double bed", although I do not suggest that there is any feather bedding in your Lordships' House. I am particularly grateful to the noble Lord, Lord Annan. His Motion has tempted me to override my natural caution and the advice given by, I think, Disraeli to a new Member who asked when and how often he should speak. "Better for people to wonder why you do not speak, rather than why you do", was the reply.

The Motion of the noble Lord, Lord Annan, is correctly focused on the essential elements of the Tomlinson Report, unlike so much of the superficial media comment. The Motion lays stress on the need to improve primary care and on the major reforms of medical education and research in inner London hospitals which must also be carried through after proper consultation and with real sensitivity. I should declare an interest as a trustee of a medical charity and a non-executive director of an international health care company.

Of course, the patchwork pattern of London's great medical schools should have been transformed many years ago, as the noble Lord, Lord Annan, indicated, but their defences were strong, their traditions much respected and their trustees and patrons powerful and well placed. But times have changed. It is now just plain wrong to resist what I believe are constructive and necessary pressures for reform.

Account must be taken of the undoubted fact that hospitals in inner London consume much more than their fair share of NHS resources in England. Costs are too high and efficiency and effectiveness are too low. What a pity that greater care, or perhaps more effective control, was not exercised over major hospital building projects in inner London in recent years. Arguments about recent capital expenditure must not mask consideration of revenue costs, which are invariably more significant in the long run. What was concealed by the special funding arrangements of the past is being stripped bare as the recent "purchaser/provider" split of the NHS reforms takes effect. Sensible purchasers will not be prepared to pay the excessive cost of hospital treatment in inner London. The consequential reduced activity will make matters worse. We should never forget that patients usually much prefer to be treated locally whenever possible.

The status quo is not an option. While due weight must be given to the many closely-argued representations being made —and we have all received them in every post-bag—I hope that the anguished cries for special pleading for particular institutions or specific causes will not drown out the more resonant and responsible rumbles of support for long-awaited and much-needed reform.

In the context of special pleading, I must express my anxiety about the reported use of charitable funds for public relations companies on what is essentially polemical if not political campaigning. Patients are much more important than institutions. Primary care provision in London is extremely patchy. It is superb in some areas but too often it is well below national standards elsewhere, as the noble Lord, Lord Annan, so eloquently pointed out. The facts are well-known. There are too many aged GPs who are too frequently working single-handed with above average patient lists. They are working from inadequate premises with too little professional support among communities with many disadvantaged groups requiring special attention. It is no wonder that so many local residents, as well as many homeless people, seek medical help from the accident and emergency departments of their local hospitals, often waiting hours for simple treatment that should be readily and speedily available from a GP. That highly unsatisfactory state of affairs has been tolerated for far too long. I welcome the Tomlinson proposals for dealing with that deep-rooted problem.

As the report makes clear, money up front will be required to improve primary care, particularly GP practice premises. Essential action is needed to facilitate the cost-effective transfer of resources from the hospital sector to primary and community care.

Medical education and clinical research are of immense importance. Reorganisation must protect and enhance those centres of excellence for which London is rightly renowned. But the London medical schools and research institutions have no monopoly on excellence and proposals for change must be seen in a national context. I commend Malcolm Green's interesting British Medical Journal article and I welcome the co-operative progress being made by, for example, University College Hospital and the Middlesex.

The general thrust of Tomlinson is in harmony with the excellent King's Fund London Commission Report. The BMA, the RCN and much other informed opinion is generally in step. There is even the imprimatur of a Guardian editorial.

None of that will be easy. Special interests, Treasury control, the collapse of land values, the sheer inertia of deeply entrenched institutions will all combine to resist significant change. But change there must be. I used to think that reorganising the British Army—amalgamating historic regiments and the like —was one of the most difficult tasks. That was before I encountered the British medical establishment. But I have confidence in the persuasive powers and determination of my right honourable friend the Secretary of State for Health and her ministerial colleagues. I wish them well in their tasks.

3.51 p.m.

Lord Hunter of Newington

My Lords, my first and most pleasant task is to congratulate the noble Lord, Lord Hayhoe, on behalf of the whole House for what must have been one of the most stimulating addresses we have heard—stimulating but not controversial. On behalf of the House I say, "Hasten back and speak to us again soon".

I should like also to congratulate Sir Bernard Tomlinson and his colleagues on a remarkable report which I hope will stimulate profitable discussion among those concerned. I was first concerned with the matter in 1968 when I was chairman of the medical sub-committee of the University Grants Committee and wrote a report on the London teaching hospitals —after Todd. As far as I know it had no influence whatever. Since then there have been a number of other reports. I think it is wise for the House to note at this early stage of our discussion the timescale of some events in London.

Sir Bernard Tomlinson is to be congratulated. He took some of the principles regarding general practice secondary care centres, suggested originally many years ago by Lord Dawson of Penn, and developed them in a remarkable and positive way. I must confess that not being a Londoner there are many aspects of the teaching hospital recommendations which I feel I cannot profitably discuss, but there are many people here who will do so.

What requires to be achieved? Whatever the outcome, London teaching hospitals and medical schools must maintain their position of eminence and high quality; but also, as has been said, the patients in London and the general practitioners who hold responsibilities for them must also be considered, otherwise the whole business will be inefficient and of poor quality. That includes the training of doctors.

Some 10 years ago the Acheson report made it clear that London practitioners had large numbers of patients, fewer staff and offered fewer specialist services. The urgent question is whether there should be an increased number of group practices with secondary care facilities, and that means accommodation which has always proved difficult.

Two years ago I had occasion to examine the costs of eye testing. I give only one example of the changes. For a patient to be examined in an optician's clinic, perhaps by a medically qualified person, the cost is around £10 per head. To send the same patient to the hospital for the same examination by an ophthalmologist, the cost was £23 per head. In the past there was little that ophthalmologists could do for their patients. Now there is a whole battery of special services; lens replacement, laser treatment and other scientific advances have revolutionised the position. That is only an example of what is happening in a whole range of other situations. When I was a young doctor doing general practice we sent patients to hospitals for almost all investigations. Now what is required is better services in the general practice group which offers a range of facilities. That is not only satisfactory to the patient, as has been said, but it costs less.

The Tomlinson report states, We are aware that there are also serious inadequacies in primary health services in inner London. The difficulty in securing good quality premises lies at the root of many of the problems surrounding general practice in inner London". Paragraph 37 states: We have been told that DHAs [district health authorities] and trusts are sometimes reluctant to cooperate by selling surplus hospital estate for conversion into facilities suitable for the development of primary care". One of the most important priorities and probably the key priority in a major reorganisation of capital resources in London is that it provides an opportunity for cost effective re-use of assets. One also wonders whether the director of research and development should be involved at an early stage in the discussions with the objective of determining the best and most effective ways of providing secondary care services.

Will the Minister encourage the director of research and development to explore, with representatives of GPs, the production of what Tomlinson calls "primary care development zones"? I believe that the director of research and development should be involved in the matter and be a member of the implementation group, because whatever happens in London in the development of general practice will have the greatest importance and significance for other parts of the country. I should like to suggest that there should be several experimental practice groups within the inner London area and a serious attempt should be made to determine which modern facilities of diagnosis can be accommodated and adequately used within a six to 10 group practice. That could include a wide range of provision including pharmacy.

Last year the National Health Service drug bill rose to £3 billion. One of the consequences of practices becoming fund holders is that they are now becoming aware of that. Overhauling of practices' prescribing policy should be a top priority with doctors whenever they decide to become fund holders. The majority of prescribing in the Health Service is done in general practice. It is in that area that the greatest potential for reducing the drugs bill exists, with the present structure of general practice, as we have suggested, involving shared patient care between doctors.

Tomlinson's detailed proposals for the hospital changes suggest that bed capacity in London should be reduced and in some cases whole hospital sites taken out of use altogether. It is urgent that the programme should start soon but it should be done in a way which inspires confidence in the staff. In some ways that is the most difficult task because, whatever happens, the quality of the service given by those people must be maintained and their eminence in clinical teaching preserved. In the past caring was the prime concern of doctors, nurses and others in contact with the patients. New management structure requires collaboration between management and those concerned with patients.

Baroness Trumpington

My Lords, order! Time, gentlemen, please.

Lord Annan

My Lords, I did ask that my time, which I deliberately did not extend beyond 20 minutes, could be given to my noble friend Lord Hunter.

Noble Lords

Hear, hear!

Lord Hunter of Newington

My Lords, my final point is that one has to remember the health services Act of 1990 and the reforms that were introduced as regards purchaser choice and provider competition. Tomlinson is a planned approach to health care to be carried out by management. The skills and medical advisory system of the director of research and development is required to advise the management board on the implementation. How does one provide stability for specialised services and at the same time the benefits of purchaser choice and provider competition? Perhaps the Minister would like to say something about that.

4 p.m.

Lord Molloy

My Lords, I too congratulate the noble Lord, Lord Annan, for introducing this debate and also my noble friend Lord Desai for his speech. They were two good speeches which set us on a good road.

The Tomlinson report is an extraordinarily valuable document for those of us who are interested in the National Health Service. I learnt so much when reading through it. I am not going to say that I agree with everything, but it is a valuable document. In the little time at my disposal, I shall concentrate on two hospitals in the London area about which I know quite a good deal. One is the Royal Brompton Hospital and the other is Bart's. There is so much that makes sense in the Tomlinson Report and so much to which I believe the Minister will give attention.

At the same time one cannot find a document during one's lifetime of the width and breadth of Tomlinson, and then agree with every single word and recommendation contained in it. It would be an error to do away with the Royal Brompton Hospital which was opened only last year by Her Majesty the Queen at a cost of £45 million. I am informed that it is one of the finest heart and lung specialist hospitals in the world.

The same applies to Bart's. Wherever one travels, whether in America, Australia or Europe, and questions as regards hospitals arise (usually in connection with the National Health Service) Bart's is always mentioned as a great hospital. It has special trustees. They have committed £14 million from Bart's endowments to its now famous medical college, the college of nursing and midwifery. I cannot imagine that anyone who agrees with modern medicine deploring or disagreeing with that wonderful endeavour by Bart's. That hospital serves the City, Hackney and the commuters. Its trustees are of the opinion that while Tomlinson contains so many good things, its vulnerability tests are somewhat flawed.

I also believe that the Royal Brompton Hospital and Bart's recognise the need to rationalise London's health facilities, but not to destroy British hospitals well-known worldwide which serve our nation and London. Bart's, as one of the United Kingdom's great hospitals, has a worldwide reputation and it is linked with Homerton Hospital. If Bart's is closed then Homerton will also be closed. Over £100 million has been given in charitable donations and all that may be lost if those hospitals are abolished.

The Tomlinson Report states that the survival of London's hospitals will depend on efficiency. That is a good and admirable test. If such a test were even on a worldwide basis, let alone a British one, Bart's would survive. The evidence for that should be examined. Before Bart's is destroyed, I hope that the staff, doctors, nurses and teachers who work there will be consulted about their views. In my discussions with them they have taken a very admirable point of view. They agree so much with Tomlinson, but they are unable to accept some of the recommendations. Tomlinson ignored the evidence about Bart's world-renowned efficiency and its massive service to North-East London. That service provides for people from all over Great Britain. The City and Londoners want Bart's kept. Let us not wilfully destroy that great hospital which is renowned throughout the world.

Bart's and the Homerton Hospital trustees expect to be constantly consulted because they believe—and I agree with them—that they have produced one of the most efficient systems of hospitalisation that mankind has seen. Are we going to destroy that just because of a quick report which has so much good in it, but which destroys very quickly? Change can be implemented from many parts of Tomlinson; but we must avoid disaster. It would he a disaster both for London and the nation if these two great hospitals which I have mentioned were destroyed.

In conclusion, let us have the best of the Tomlinson recommendations and the courage to reject those about which we are somewhat apprehensive. Some of our great hospitals should be maintained and in that number I include St. Bartholomew's. Therefore, if we can have the best of Tomlinson, let us make sure that we in no way destroy great hospitals which have already been proven beyond peradventure as being great assets to this country and great guides to other nations.

4.6 p.m.

Lord Braine of Wheatley

My Lords, when I look back over my 42 years of continuous membership of the House of Commons, I can honestly say that my most rewarding experience was serving as Parliamentary Secretary at the Ministry of Health in the early 1960s under the inspired leadership of Enoch Powell when he launched his massive hospital building programme and a major reform of our local authority services. What was done then was timely and right. I found it immensely exciting. It laid the foundation for better medical care for all our people.

But medical science does not stand still. As the years advance more illnesses are diagnosed and new methods of treatment are introduced. Government have a responsibility and a continuing duty to see that the best possible care is provided for the sick, disabled and the elderly, and to make the necessary changes. At the same time I agree with a great deal of what was said by my noble friend Lord Hayhoe.

For those reasons I do not question the timing or the purpose of Sir Bernard Tomlinson's report on health provision in London. But I am deeply concerned about some of his recommendations. I must speak as I feel. Since of necessity I must be brief, I shall refer to just one recommendation; namely, that St. Bartholomew's Hospital, which has long enjoyed a worldwide reputation for excellence, should be closed with no regard whatever being paid to the fact that over the past five years some £60 million has been spent on providing it with new wards and operating theatres which match the best in Europe.

Without providing any convincing figures, the report asserts that London has an excess of beds. At least, that is without foundation where Bart's is concerned because 40 per cent. of its specialist services are for local London patients. A further 36 per cent. is for patients from elsewhere and the North East Thames Region. Currently, Bart's has a long waiting list for routine admissions, which is hardly surprising for a hospital with such an excellent reputation.

Let us consider the achievements of this very remarkable hospital. In the past 13 years, although the actual number of beds has been reduced by 44 per cent., 53 per cent. more in-patients have been treated as a result of improved methods and more day surgery. The number of patients treated as day cases has increased by 123 per cent. Yet Tomlinson recommends closure and merger with another hospital. Closure would threaten the work done at Bart's for patients with cancer, including children with cancer; the care of those with cardiac disorders, heart surgery, the treatment of AIDS and the provision of transplantation services. I am advised that Tomlinson did not even bother to visit the hospital's research campus before making his recommendations, although closing Bart's will inevitably damage its internationally-acclaimed research; nor did he make more than a fleeting mention of the quality of medical care; and he totally ignored patient and general practitioner choice. I would urge the Government therefore, before any decision is reached on this matter, to seek the views of general practitioners in London and in the north-east Thames area who send their patients to Bart's or who would like to do so.

Finally, in my view it would be the height of folly to endanger the highly specialised work which is done at this remarkable hospital. For example, one-third of adult patients treated there for acute myoblastic leukaemia, formerly a fatal condition, are alive 10 years later, as compared to a national average of less than one-quarter. Also, Bart's provides the only comprehensive service in the country specialising in children's eye cancer, a condition which can lead to blindness. Tomlinson ignored the fact that Bart's is not just a London hospital. One in five eye cancer cases treated there comes from abroad.

I have tried to measure my words carefully but frankly, in my view, it would be disastrous to interfere with work of this calibre, built up with enormous expertise over the years and, if I may say so, with loving care over the last few decades. Surely commonsense calls for the rejection of this ill-considered and insensitive proposal.

4.11 p.m.

Lord Richardson

My Lords, I am honoured to be allowed to voice on your behalf gratitude and congratulations to the noble Lord, Lord Braine of Wheatley, for his very vigorous maiden speech. I am particularly in his debt because it is my strong desire to talk about St. Thomas's Hospital, not in the same terms as he has talked about Bart's, although the name, "St. Thomas's" could have been substituted for "Bart's" all the way through with equal truth and I should be delighted if it was with equal effect.

I should like to point out to your Lordships that one of the most self-evident but nevertheless important aspects of all medical care, and one in which administrators, doctors and indeed government are most vulnerable, is the adequacy of accident and emergency hospital services. Their effectiveness and adequacy depends to a very large extent on their location. The location of our accident and emergency unit, for those who are privileged to work in the Palace of Westminster, is across the river. That is a remarkably valuable position for dealing with perhaps one of the most vulnerable and certainly one of the most significant areas in the whole of this kingdom; namely, Westminster. It is quite unnecessary to point out the fact that other hospitals could do the work most admirably, but our position across the river happens to have what has been gauged by a method called the isochrone. Doubtless your Lordships know what that means. In essence it means that it takes 10 minutes in time from the point of the accident to the department. The isochrones for St. Thomas's Hospital include the whole of Westminster, the Royal palaces and the great railway stations of Waterloo and Charing Cross.

What has St. Thomas's to offer to meet this demand which is placed upon it through the time factor? It has already 70,000 patients a year to serve and the number will be 100,000 when the Westminster casualty department is closed. It is in the process of being enlarged and refurbished at a considerable cost (£3.2 million). It is supported by a very effective hospital; a hospital that not only treats patients on a national basis but—and this is extremely important in relation to London—treats those who are locally related to it. Therefore, two-thirds of patients at St. Thomas's come from the district, in the old-fashioned sense of the term, and of the money that is given to the hospital through the Treasury the percentage is again extremely high at 88 per cent.—much higher than some other hospitals—thus indicating the necessity for the hospital to be dealing with the local population.

The hospital is strongly supported in its position there by the general practitioners of Lambeth, Westminster and Southwark. Indeed, over 50 per cent. would regard it as a disaster or a near-disaster if it were to be closed. Thus, on that one point alone—that extremely important point—I feel that St. Thomas's will have to be considered as a "must" very carefully indeed by Ministers when they are taking their very difficult decisions.

Finally, I should like to point out that with the many admirable features of Tomlinson, the timing seems to me to be suspect: perhaps a better word would be "optimistic". To feel that general practice can be raised to the standard required to replace what is being done already by the great teaching hospitals is very optimistic indeed. It can be done and it will be done, but it takes time and it takes training.

4.18 p.m.

Baroness Jeger

My Lords, Tomlinson states on page 3 that the intention is to develop, a programme for change from the 'bottom up', building upon consensus, rather than merely devising our own blueprint". I want to use my few minutes to speak very much from the bottom of the scale. I feel that the "bottomers" have not received much consideration in the report. In fact, there seems to me a total lacuna about patients' wishes. If the gentleman from Newcastle had walked past University College Hospital today or if he had received some of the petitions that many of us have been receiving I think he might have put in a few paragraphs on the matter.

I never progressed further in these matters, except by marriage, than to become a very keen if not very efficient VAD at a casualty clearing station in the last war. I have a strange sort of memory of those days. We did not have time to look at the buildings or to count the costs because we were only concerned with looking after patients.

Hospitals are rather like coal mines. Any fool can shut them down but it takes something in advance of genius to resurrect them. I should have thought we would have learnt lessons from the past. I can remember when the fashion was to close the cottage hospitals because only the big teaching hospitals were important. What a pity that was. We could do with those small local hospitals now for use as hospices and in all sorts of other ways. After that the fashion switched to closing down the mental hospitals. What happened to the patients? We had to slow down the programme because of the distress among patients and difficulties for the police, the prison officers and magistrates. All that resulted from the mania for shutting down hospitals. Many of us are now worried about the switch to more community care. We are not sure that the infrastructure will be in place before the local authorities have to take on those onerous tasks.

I read carefully a report from the Association of Local Authorities. The association is puzzled, as I am, by the extraordinary statement that there are too many beds in London when London waiting lists are the longest in the country. An interesting letter to The Times yesterday from a professor at St. Thomas's stated that junior doctors recruited from outside London were totally "gobsmacked" on their first day at the amount of work they had to do and at the impossibility of admitting patients when their previous experience would have led them to agree that those patients needed to be admitted. Many of us are puzzled. We cannot find a hospital in London that does not have a waiting list both for in-patients and out-patients.

I know a lot of doctors, thankfully. I do not know of one who has been able to find a hospital where the junior doctors work the number of hours recognised even by this Government as ideal. The overtime still continues. We are talking today about a report with some good suggestions in it. I am not trying to be totally destructive. I seek only that the good things and the changes that need to come about are somehow managed in a way that does not mean just closing down hospitals in a negative way when they still have a great deal to do.

I am encouraged to say this because last week in the other place there was much talk about patient choice, about charters galore. There was a Minister singing like a psalmist trying to sell the ark of the covenant about how patients should choose and how passengers should choose. Choice was to be the watchword of this Government for the future. I cannot imagine a greater deprivation of choice than to deny people the chance to attend the hospital of their choice, a phrase often used in the last election. Sadly, these proposals, if carried out, would mean a total absence of choice. That cannot be right.

There has been no request from the Royal Marsden patients that their hospital should be shut down. All the indications are to the contrary. Let us keep our hospital. If the Government and some other people are to take the view that doctor knows best and Ministers know best, well that is not a fair assessment of the real needs and real wishes and what would be a good future for our hospital services.

4.23 p.m.

Lord Joseph

My Lords, I regret that I cannot stay for quite the whole debate because of a long-standing commitment later today. The noble Baroness, Lady Jeger, has touched the conscience of many of us who have been involved in some of the changes dictated by the fashions and best opinions of the time in taking out of action some of our old institutions. But I call the noble Baroness's attention to paragraphs 89 to 93 of the Tomlinson Report, which talk about the scope of some of the hospitals in London, even the most famous, for increasing their turn-round of patients, which would of course have some effect on waiting lists. Who am I to make any criticisms? I am not making criticisms. But Tomlinson devotes several paragraphs to precisely the subject of reducing waiting lists through improved efficiency.

I want to speak of the inadequate primary services in London, to which Tomlinson gives his main purpose. I note that on precisely the same subject the Acheson group produced a large report in great detail on precisely the same subject 10 years ago. I call the attention of noble Lords to an article in the British Medical Journal two weeks ago by Brian Jarman and Nick Bosanquet, pointing out that London's primary services have improved in the last 10 years since Acheson. But, alas, they have improved only as part of an overall improvement of primary care in the country as a whole. In other words, the Acheson Report on the inadequacies of London primary services 10 years ago has not achieved the London improvements it recommended.

I do not need to describe to your Lordships the inadequacies of London's primary medical and related services in relation to the unique scale in the United Kingdom of London's medical and related needs, so well described by Tomlinson. My noble friend Lord Hayhoe, in a notable maiden speech, made it the main subject of what he was saying, as of course did the noble Lords, Lord Annan and Lord Hunter.

Tomlinson proposes financing the improved primary services in London that we all regard as so necessary by savings from rationalising some of the hospital services. I hope that my right honourable friend the Secretary of State for Health and her colleagues will be able to surmount some of the hurdles in obtaining the money for the improvements that Tomlinson recommends. My noble friend Lord Braine, in his maiden speech, gave an example of some of the passionate defences that will be mounted before Tomlinson can garner some of the savings from which he recommends improvements in the primary services can be financed.

Let me add a few. We know that the medical profession will erect all sorts of resistances—no doubt honourable resistances—to the devotion of any savings achieved just to services in London. They will want the benefit to be shared in the whole country. That is what is likely to happen. I am giving away no secrets when I say that on my way to your Lordships' Chamber a Scottish friend said to me, "My interest is to see whether we can get some of those savings for Scotland." Well, good luck to that noble Lord, but it is going to be a problem for my noble friend and the Government to overcome.

Extra money is needed to set the whole process of Tomlinson in motion. That will be a problem too, and so is the sordid but real fact that different budgets are involved in relation to hospitals on the one hand and primary services on the other. We have to ask ourselves, as the noble Lord, Lord Annan, invites us to do, why there have been no results for primary services in London first from Todd, then Flowers, then Acheson, and whether there now will be from Tomlinson. I wish my right honourable friend the Secretary of State for Health and her team great resolution and luck in carrying out Tomlinson. I wish them well.

4.28 p.m.

The Duke of Gloucester

My Lords, I am speaking this afternoon as president of St. Bartholomew's Hospital, an honorary position that I hold with great pride, as did my father before me and indeed Prince Albert in the days when so much was donated by private subscriptions. I am speaking on behalf of St. Bartholomew's and its other hospital at Homerton, which serves its community in the East End so effectively. I cannot speak for the other hospitals threatened because Bart's is the only one with which I have been familiar for many years, and I am frankly amazed that its future should be in any doubt.

This period has been set aside as a period of consultation on these proposals. Yet I wonder whether it is an adequately long period to demonstrate that a number of the premises on which the report was based have proved mistaken, at least so far as concerns the section referring to the destruction of St. Bartholomew's.

I should like to draw your Lordships' attention to five points of error in the Tomlinson Report. The first point concerns the catchment area. The report describes Bart's as having a catchment area of 35,000 whereas in reality it is 220,000, including South Islington and South Hackney. A very high proportion are, for demographic reasons, elderly people, in an area with virtually no medical facilities specially for the elderly. This number is boosted to half a million every working day by commuters to the City. Bart's not only provides them with emergency cover but also provides treatment for minor ailments that can be dealt with in a few minutes during the lunch hour, rather than taking a whole day off work to visit their local hospital.

The second point of error is demand. Tomlinson implies that the fact that a larger than normal proportion of patients come from outside the catchment area is a negative quality, whereas in the real world it would imply that its reputation for effective medicine is a positive strength. There is a strong demand for Bart's medicine, partly I suspect because of the reputation that Bart's has for being in the forefront of world research in so many fields—a fact totally ignored in the report. Specifically, cancer, eye cancer, heart disease, hormone disorders, AIDS and inflammatory bowel disease in children are all fields in which the pre-eminence of Bart's is recognised. Not surprisingly, Bart's is second only to Oxford as a receiver of medical research grants. It has been suggested that this talent could easily be dispersed to other hospitals, but I feel it is unlikely that doctors who have built up over many years a reputation that has resulted in the provision of the most modern facilities costing £60 million should meekly retire to the suburbs to start again and risk seeing their life work again disbanded in the name of efficiency. No, that talent will gravitate to excellence and to where it is valued, for medicine knows no national boundaries. It will be lost to London, and probably this country.

The third point to raise is that of efficiency. Whichever way one measures efficiency, Bart's has a fine and improving record for patient care. A carefully constructed day care centre has ensured that not only is appropriate medicine provided in purpose-built surroundings but that the community is served in a cost effective manner. Tomlinson ignored the region's own figures that "bed use" at Bart's was the most efficient of all in central London.

The fourth point is location. Tomlinson implies that London would be adequately served by emergency services without Bart's. It uses figures to prove this, including the assumption that Bayswater to Bart's is only a 10 minute journey. This is not possible, I suggest, even with a police escort. London, as we all know, is hugely congested, and it is no good applying standards suitable for a new town type road system to heavy city congestion and then being disappointed by the consequence.

The City has its fair share of disasters, as demonstrated by Tube crashes and terrorist bombs. Imagine what would have happened if the IRA had managed to get its bomb to the Lord Mayor's show. Sadly, there will continue to be accidents and the City needs its hospital.

Lastly, the report implies that our site would be highly valuable for redevelopment. This assumption is based on the hope that developers would want to build office blocks. No developer would want to touch such a problem site. First, it is in a conservation area; secondly, 75 per cent. of the hospital is composed of listed historic buildings. The main blocks were designed by Gibbs in the early 18th century and are listed Grade 1. As a commissioner for English Heritage, I know that we would be failing in our statutory duty if we allowed any alteration to these buildings of anything but a very minor nature. They thrive as hospital buildings; they would be inconvenient and inflexible as office buildings. The whole site is severely constrained because of its archaeological significance; the Roman Wall, the mediaeval buildings—for any developer a nightmare. The north block which is such a blessing for the hospital is also for good measure scheduled as an ancient monument.

It is difficult to see it appealing to any commercial organisation and it would be impossible to build any large new buildings on the site.

London is now so full of surplus office blocks that it would be at least 20 years before anyone would voluntarily tackle this problem site. Who will look after it meanwhile? No, Sir Bernard, the sale of this site will not fund the millions for redundancy that you propose. It will instead become a drain on national and City funds until some new use can be found—perhaps a museum of pioneering medical practices that this country used to lead the world in.

Bart's is not afraid of the chill wind of accountancy which is blowing through the health service. It has stood up to the tests of demand and efficiency. Its complaint is not that they should not be applied to it; it is that they have not been applied accurately and impassionately.

I beg for a stay of execution for Bart's, an institution whose crime it seems is to have tried too hard, if not too politically, to serve its community as well as possible. It has a plan of its own for the future. Please consider it. It is prepared for change but not extinction.

4.36 p.m.

Baroness Jay of Paddington

My Lords, I should like to give my thanks to the noble Lord, Lord Annan, for giving us the opportunity to debate the Tomlinson Report today. It is a very timely moment to do so because I am increasingly finding in London, as these proposals are more widely acknowledged and more and more understood, that there is growing apprehension and concern about the proposals. I should like to echo what was said by my noble friend Lady Jeger about the emphasis that must be put on the wishes and needs of patients. Any change which the Government propose to introduce on the basis of the Tomlinson Report must focus on the needs of Londoners, must have their confidence and must be properly planned and gradually introduced. At the moment there is considerable scepticism and concern that change will simply mean a reduction in services.

Other noble Lords have drawn attention to the inadequacy of general practitioner services and primary care services in London. Given the time constraints this afternoon, I do not need to repeat them. However, I think it is important to repeat some of the details of the population with which those GPs and family practitioners are dealing. They are dealing with a population in the inner city where mobility and social deprivation often make it impossible to establish traditional patterns of primary care. If you are a single parent in bedsit accommodation, or if you are one of the 66,000 people who are now assumed to he sleeping rough in London, it is unlikely that you will develop the kind of cosy secure relationship with a family doctor which may happen in more settled communities. That is why Londoners often use hospital out-patient departments in what are seen as inappropriate ways by health service managers. Accidents and emergency services are used in ways which certainly would not be used in other centres.

Perhaps I may give an example which is close to my knowledge. It concerns the St. Charles Hospital in North Kensington where I am a member of the local district health authority. A recent survey of patients using the accident and emergency services at the hospital showed that more than half were those who could more appropriately be categorised as people who needed primary care. They should have been looked after by family doctors, but the family doctors are not there. Now it is proposed—for reasons that have little to do with Tomlinson—that the accident and emergency department should he closed. What will happen then to the large number of people who have used it for primary care?

St. Charles Hospital is a microcosm of the general problem about primary care which has been highlighted in the Tomlinson Report. In North Kensington we are now beginning to draw up new plans to create primary care services. But that will take time and money, and to do this across London will take a great deal of time and a great deal of money. I hope that when the noble Baroness replies she will be able to give us some indication that adequate new resources will be available to fill the gaps which must be created in primary care if some of these accident and emergency departments and other facilities are to close.

The King's Fund London Commission Report on London hospital services in 2010, which has also been referred to this afternoon—the Minister was a member of the commission that did that report—stated a few months ago that £250 million would be needed to finance any kind of respectable upgrading of primary care services. The figures which are now being rumoured about the Government's spending plans in that area are considerably and alarmingly lower. I hope that the Minister will be able to tell us that primary care investment will be up to the figure that she recommended earlier.

The other vital question relates to timing. If Londoners are to have confidence that their services are not just being cut, the new investment must be made before and not after changes are made in the hospital sector. Sir Bernard Tomlinson underlined that by noting that hospital expenditure is not flexible in the short-term, so: redirection of resources can only be achieved by providing new money to facilitate change". The Tomlinson Report could provide an exciting catalyst for change in primary care services in London. Well-equipped local health care centres, staffed by nurse practitioners, GPs and perhaps a peripatetic consultant could begin to redefine the traditional boundaries between primary and secondary care; for example, minor surgery or looking after the chronically ill. But such change can only be achieved gradually because it requires not just financial investment but careful planning, retraining, and indeed a change in the culture of medical practice and health services in the capital.

It will be reassuring if the Minister can tell us when she replies that pilot schemes will be developed. Here I was interested in the remarks of the noble Lord, Lord Hunter, about involving the director of research and development for the health service in that process. That has the potential for some interesting ideas. If we can have some pilot schemes, change will not occur universally, uncomfortably and overnight as it did two years ago when the NHS created the internal market.

At the moment Londoners are apprehensive because they are doubtful that adequate resources will be found to finance primary care before hospital closures happen. They are concerned that changes will be made, based upon decisions about institutions rather than upon a broad assessment of population needs.

4.42 p.m.

Lord Carr of Hadley

My Lords, I too start by thanking the noble Lord, Lord Annan, for giving us this opportunity to debate the Tomlinson Report, and most warmly congratulate our two maiden speakers, my noble friends Lord Hayhoe and Lord Braine of Wheatley. Perhaps I may say to them at a selfish level what a pleasure it is to be rejoined by them here in the calmer seas of your Lordships' Chamber after many years in another place.

Because of time constraints, I intend to mention briefly just four headline points, all confined to general principles and not the recommendations about particular hospitals. My first headline point is that I believe strongly that the report's basic analysis and its consequent diagnosis of the problem to be solved is unanswerable and we must accept it—that is, there is an urgent need that must be met for more and better primary care throughout London; and, secondly, there is a need and scope to reduce the number of acute hospital beds in the London area.

It is therefore clear that radical action will have to be taken. Radical action always produces opposition. In order to meet such opposition successfully, we must be as sure as we can be that the action taken is soundly based. That brings me to my second headline point; namely, the report's detailed recommendations for the rationalisation of London's hospitals. Those recommendations do not fill me with the same confidence in their solidity as does the report's analysis. I feel that the committee's methodology in assessing the prospects of different hospitals needs close further scrutiny. In addition, while I agree with the report that the whole of the reduction in beds cannot be achieved by piecemeal bed closures and savings in each hospital, I believe that as much as possible should be achieved in that way, and as little as possible by the closure of whole sites and the relocation of essential special services from one place to another.

I cannot but feel that the report has come down too heavily on the side of upheaval, of complete closures and numerous major relocations. I do not believe that the committee appreciated the full costs of carrying out all those proposed wholesale closures and relocations. If it has, it has not disclosed them. The costs are enormous. That is not made clear in the report.

I also feel that the report shows a too easy confidence in the practicability—even if it were desirable—of selling abandoned buildings or converting them to alternative uses. That would be difficult at any time, but with the property market as it is at the moment and is likely to be for some years to come, the problems have been under-estimated. To embark on that programme could well lead to disaster.

My third headline point relates to where we should start with those major difficult reforms. The reforms will be expensive, however skillfully they are thought out and done. In the end, they should produce economies, but the spending will come first and the savings will come a long way down the road. That presents a difficult financing problem for any organisation, most of all for a Government with Treasury methods of annual control, and so forth. I feel that I must say to the Government that to carry through that radical reform successfully they must start by providing for improvements in primary medical care. They must give to the people of London, the doctors and hospital staffs, a real taste in their mouths of those improvements before they will successfully carry through more controversial, naturally suspect and unpopular parts of the hospital rationalisations. If my noble friend the Minister does not have sufficient money to do that, I say to her, "Please do not start until you have, because to start before you have could lead to a serious problem".

That brings me to my fourth headline point. I cannot help but express my dismay—I cannot think of a less strong word that I am prepared to use—that the review by the Tomlinson Committee did not include a review of the top hamper of health service administration in the London area. In the report the committee said that it could not recommend an extra layer. It went on to say, as a self-evident assertion, and without any argument, that it could not recommend a single London health authority. It then went on to say that, nevertheless, it must have such a one to put over the four existing authorities in the implementation group, although the committee says that is to be temporary and not statutory, but temporary things have a habit of lasting, and we cannot afford yet one more layer in the top hamper of administration.

I am aware that there are difficulties. I know that it may need primary legislation. I do not in any way belittle the work done by those who head and work in the four regional hospital boards, but on any managerial principles that set up is crazy and there will not be the release of full energy at operating levels nor a proper reduction in overheads until that matter is tackled, and sooner or later—sooner rather than later —tackled it will have to be.

4.48 p.m.

Lord Walton of Detchant

My Lords, at a time of severe and, as yet, unyielding economic recession, I am sufficient of a realist to recognise that no government of any political complexion would ever find it possible to introduce that massive infusion of resources which the NHS could so effectively deploy in meeting the needs of an ageing population, of major developments in medicine, and of increasing—as we know is long awaited—the consultant establishment. We must therefore concentrate on what can be done within the resources available, and so the NHS must be seen to provide full value for money.

As Tomlinson has pointed out, as the population of central London has declined so the unit cost of treatment for mundane conditions in the city's fine teaching hospitals with their long and distinguished history continues to rise. In the case of many conditions, quality care can be more readily and cheaply provided in the periphery. Tomlinson has also shown that far too many specialist units exist in the present teaching hospitals, often requiring costly ancillary diagnostic facilities which could be concentrated more efficiently in larger integrated units for the so-called super specialties.

Of course, we all acknowledge the importance in Britain of our historical and cultural heritage and of the contribution made to medical care, teaching and research by hospitals like Bart's, Guy's, St. Thomas's and the others. One cannot be deaf to the clamour of the voices raised by staff and former patients who strenuously resist any proposal that these hospitals should lose their identity and in some cases their very existence.

We must also acknowledge the remarkable contributions made to national and international medical life and particularly to postgraduate education and research by the many special hospitals in London coming under the special health authorities and under the British Postgraduate Medical Federation. However, even these and other centres of educational and research excellence have sometimes suffered from their comparative isolation from mainstream university life and from hospitals providing general medical services.

For these and for many other compelling reasons, I must say that I have to support many of the proposals in Sir Bernard's report in principle, while accepting that the implementation group will be faced with an exceptionally difficult task. I also accept that those primarily involved have made several constructive and statesmanlike proposals for change which that group would do well to consider.

Since the introduction of vocational training, as many noble Lords have pointed out, the quality of general practice throughout the United Kingdom has improved beyond recognition. But, as the noble Lord, Lord Joseph, and others have said, recent articles in the British Medical Journal have pointed out that, despite some improvement in London, the major and long overdue recommendations of the Acheson Report published 11 years ago have not been implemented. The quality and organisation of general practice and community care in the capital lags far behind that in other parts of the country.

However, the necessary improvements cannot be achieved overnight. New premises and the development of group practices will help, but some retraining and an imaginative recruitment programme will take time.

In relation to hospital care, plainly some beds offering routine treatment which can be provided equally effectively in hospitals in outer London must be closed and small specialised units should be concentrated into fewer of the central London hospitals. Four larger medical schools, each firmly linked to multi-faculty colleges of London University, should also he created. But I see no compelling reason why, with the increasing use of peripheral hospitals and the community for teaching, it will be necessary to reduce medical student numbers. The consequential reduction in university funding could well have a devastating and unacceptable effect on teaching and research.

If we were to lose the expertise of many of those whose contributions to innovations in treatment and research in the capital, not least in the special hospitals, has been so outstanding, this would have an appalling long-term effect on the national and international standing of British medicine.

Redeployment and some relocation of scarce medical, teaching, nursing and technical skills rather than redundancy must surely he the order of the day. I believe that the university must be intimately involved in the implementation process.

Purposely, in the time available, I do not propose to comment upon the specific proposals made by Tomlinson relating to the future of individual, general and special hospitals. But I have to say that personally I am convinced that the decision to build the new Westminster and Chelsea Hospital, with its ravenous over-consumption of capital funds, so near to Charing Cross, was a serious misjudgment. Tomlinson is, however, right in recommending a closer integration between the special hospitals and the university on the one hand and a reduced number of general hospitals on the other. That is right, I am in no doubt.

Last but by no means least, the Government must recognise that if these proposals, or something along these lines, as finally recommended by the implementation group, are to go ahead, there will in the long term be some saving of recurrent resources. But in the first instance, major capital expenditure and substantial additional recurrent funds will be needed. This opportunity to plan and integrate medical care, teaching and research for London in the 21st century, as cogently argued by Tomlinson, must now he grasped. If not, London medicine can only he faced with a progressive process of random attrition and decay which surely none of us would wish to contemplate.

4.55 p.m.

Lord McGregor of Durris

My Lords, last July your Lordships debated an Unstarred Question on the policy of the Government for the future of St. Mark's Hospital in City Road. A recurring theme of all who then spoke was the urgency of maintaining that hospital as a centre of excellence for scientifically-based clinical research, for postgraduate and subsequent training and for the care and treatment of patients suffering from cancer and other problems of the nether regions.

Subsequently, a deputation drawn from those who had taken part in the debate waited upon the Secretary of State for Health and received assurances from him. It is gratifying that paragraph 143 of the Tomlinson Report, to which the noble Lord, Lord Annan, referred approvingly, recommends, in line with St. Mark's own wishes, that it should move "with all speed" to Northwick Park. I understand that this has now been agreed by all the relevant administrative bodies, including the department. All that remains to give assurance to the staff who have to prepare for the move is a clear undertaking from the Government that they will provide a grant to cover the costs of relocation. I told the Minister's office yesterday that I should be asking for this assurance today and I shall be grateful if the noble Baroness will give it when she replies.

It will emerge that the Tomlinson recommendation on St. Mark's is almost the only one which I regard as persuasive in the whole report. It opens with the statement that, we were specifically asked not to produce a voluminous report". That is reasonable, but any report, however short, on such important issues must be based on detailed evidence to which the reader is given access in separate volumes or appendices. From this point of view, I find the Tomlinson report unworthy of its subject. In many places, it is impossible for the reader to discover the demographic, financial or educational evidence on which recommendations are made. There is no discussion of the significance of London in Britain, other than that it is said to be unique for the volume and density of its population and the squalor of its primary health care. It is unique also for a host of other factors relevant to its university and teaching hospitals which are nowhere examined in the report.

My concern about the bases of information used in the report dissolved into incredulity in respect of some recommendations which affect the institutions about which many laymen have sufficient knowledge to form sensible judgments. Indeed, several speakers have already illustrated this from the recommendation in paragraph 119 that, We do not believe there is a long-term future for a major hospital [Bart's] on the West Smithfield site". The report says that the survival of hospitals in London will depend on their efficiency. The evidence of the North East Thames Regional Health Authority to Tomlinson demonstrates that the Bart's trust is the most efficient of all the hospitals Tomlinson examined in north-east London. Yet the report ignores this evidence when recommending the closure of Bart's. No wonder that Lord Rayner has described the report as "profoundly unbusinesslike". The demographic basis of the report's examination of patients treated at Bart's on a day basis and in other ways is so inadequate as to be positively misleading.

Several of your Lordships have already spoken of the consequences of the report's implementation in its present form. The noble Lord, Lord Annan, referred to the losses which would be incurred if the recommendations of the report in respect of the Royal Marsden and the Royal Brompton were carried out. They would amount to some £70 million. In the case of Bart's there would be wastage of £60 million on the refurnishing and refurbishment of operating theatres and the like which has been spent within the past five years. Of course, no one would maintain for a moment that the reconstruction of the London health services is unnecessary or is not indeed long overdue. But Tomlinson's scheme is not the only form of reconstruction. Indeed, as a number of speakers have pointed out, the scheme is so unsatisfactory that it merits another, more detailed and urgent inquiry.

There can be no justification for the destruction of centres of such excellence as will result from the implementation of this report without further inquiry. A reform resulting in the loss of related medical, scientific and clinical research such as was built up at Bart's—as it can only be built up over long years and which is greatly admired in other countries—will be a long-term disaster for patients in all parts of the country. Are we so poor a country that we cannot sustain such centres of excellence as well as providing good community medical provision? If it be said that I have made a special pleading, I would ask the following: have we as a country today so much in the way of centres of excellence that we ought not to plead specially for such as we have?

5.2 p.m.

Lord Hacking

My Lords, as I stand to address your Lordships I am much aware that the boomerang that I threw has come back to hit me because it was I who originally tabled a Motion in your Lordships' House to draw attention to London's teaching hospitals anticipating the publication of the Tomlinson Report. When the noble Lord, Lord Annan, tabled his Motion restricted to issues in the Tomlinson Report, it was I who persuaded the noble Lord, Lord Annan, to widen his Motion, which he graciously did, to allow your Lordships to consider the Tomlinson Report in its entirety.

Some 42 noble Lords today wish to consider the Tomlinson Report in its entirety. I have the daunting task in the five and a half minutes that remain to me to mention matters of concern to the London teaching hospitals. If I and other noble Lords who have to compress our words have a daunting challenge, none is more daunting than the challenge that faced my right honourable friend the Secretary of State for Health. The daunting challenge that faces her is not of her making but one which falls to her as the recipient of a report advocating changes which, as the noble Lord, Lord Annan, has said, should have taken place, or most certainly executed, long, ago.

It seems to me that the only way forward is to proceed by establishing some simple criteria. The first has already been much mentioned in this debate and it is the preservation of excellence. But how is that to be achieved? Let us for a moment look at the position of the special health authorities; for example, the position of the Royal Brompton Hospital and the Royal Marsden. Tomlinson in his report suggests that the way to preserve their excellence is to move them on to the Charing Cross site and therefore integrate them into a teaching hospital. The question to be asked is: is that the right solution? I tested that out today when I spoke to the chief executive of the Brompton hospital. I asked him how many cases he needed to refer from his hospital to other hospitals for the continuation of patients' treatment. His answer was one in 1,000. I hesitate to criticise the Tomlinson Report because in many ways it is a rational and sensible report but it has to be recorded that it lacks a clear factual basis. The preservation of excellence should also be considered among the many achievements and many highly successful units in the teaching hospitals. The question is: how can that be achieved? There is no answer in Tomlinson.

The second criterion is that costs should be balanced against the interests of patients, medical research and education. But again how is that to be achieved? Is, for example, the costing which has been aligned against the London hospitals a fair criterion? It does not require much intelligence to recognise that if a hospital, a SHA or a major London teaching hospital gives major surgery to a patient, that patient is likely to remain in hospital a great deal longer and take up much more bed time than a patient who is undergoing simpler surgery. Further, the costing criterion is hardly fair on the London teaching hospitals which often have to keep patients in their hospitals because of the poor social conditions outside.

The third criterion I draw to the attention of your Lordships is that the major acute centres in the London hospitals, albeit consolidated, should remain here in London. It seems to me to make no sense, and certainly to cause great expenditure, to move those units outside London, probably to places of less convenient access. It is interesting to note how many of the London hospitals are situated close to major railway stations.

The fourth criterion should be that the reduction in capacity of London hospitals should be matched by an improvement in primary care. We all acknowledge the achievements of this Government in applying to medicine the discipline of the market. I now change from boomerangs to balls. Now the ball is thrown back to the Government. May we have a White Paper which incidentally will give us an opportunity to return to these important matters? Can we have from the Government their criteria for the future of London's teaching hospitals and for the choice of sites? Can they give us a clear timetable? Can they give us early decisions on mergers—I emphasise the word "mergers" and not closures of hospitals—and then make the decisions on the sites? This is an occasion for us to work together. It is not an occasion for doctors to fight doctors and hospitals to fight hospitals.

5.8 p.m.

Lord Spens

My Lords, it is eight years to the week that my father died. I regret very much the delay in taking up my seat here. As other noble Lords will know, I have been somewhat engaged elsewhere. However, having said that, in the 50 hours I have been here I wish to thank the officers of the House for all the help they have given me.

I am able to speak on this subject with a certain degree of emotion because I have been on the operating tables of three of the hospitals in question which are in the vulnerability table. They are St. Bartholomew's, St. Thomas's, and Guy's. Indeed a few months ago a heart surgeon from Guy's held my heart in his hands. Therefore I have great emotional commitment to those hospitals.

I took the report home to read, and I found to my horror that it is written in code. So I employed my Enigma machine —my wife, who can do The Times crossword in under 10 minutes—to help me decipher it. Believe it or not, there are some 40 plus acronyms in the report. When analysed those acronyms break down approximately 20:20— 20 representing what I would call bureaucracy: the health authorities, service companies, councils and committees. That is a mind-boggling number of bureaucracies for any organisation to cope with. Given the experience of doctors and the centres of excellence which they represent in dealing with those bureaucracies, it is remarkable that we have a health service of such quality at all. The conclusions on page 57 of the report make no comment on reducing that manpower. It does not appear that any consideration has been given to that possibility.

If noble Lords were in a different situation and, for example, Oxford colleges—and I say Oxford colleges because Cambridge colleges are light and airy—were dealt with in a similar report which had reached similar conclusions and those colleges were under threat as centres of excellence, I wonder what the reaction would be.

It appears to me that this report does not go halfway to analysing the problem. I do not believe that at the end of the day any of the conclusions which the report has produced will resolve the particular problems which London faces.

5.11 p.m.

Lord Young of Dartington

My Lords, on behalf of the whole House I should like to congratulate the noble Lord, Lord Spens, on the speech he has just made. I hope that there will not be such a long gap as the one to which he referred before he gives us the benefit of his views again. I should also like to say how sorry I am that my noble friend Lord McColl of Dulwich appears after me in the order of speakers as I regard him as my mentor on questions such as this.

At present, inner London has a unique mix of excellent hospitals and, by and large, the worst primary care services in the country. The noble Lord, Lord Joseph, spoke about that and the recent paper by Professors Jarman and Bosanquet in the British Medical Journal. It has been generally agreed so far in the debate that if hospitals are closed without prior action being taken that already bad situation will get worse. That is especially so because at present the excellent hospitals to some extent make up for the poor primary care services. Their accident and emergency departments serve tens of thousands of people who are not registered with GPs for one reason or another—the homeless, refugees, tourists, transients and commuters, who may be registered with GPs but not in London.

There is a feasible, or at least partially feasible, alternative if resources are made available. If the primary care services of inner London were reorganised with London's special needs in mind and a great deal more spent on them, perhaps those people who make London's needs so different from any other part of the country would be properly served by new GPs, nurse-practitioners and other types of nurse based outside hospitals. Good GP-based primary care will have been built up to take up the slack.

However, as already pointed out, it all depends on the timing and on primary care services being built up before hospitals are closed and not afterwards, as my noble friend Lady Jay said. That will take years to achieve. Old surgeries need to be refurbished, and new ones need to be built. Doctors in single-handed practices need to be persuaded to join with others, and young doctors who have, with wonderful exceptions, shunned inner London for so long need to be persuaded to work in London. That will only happen if they see signs of more resources being available for them. It will take years, and it is relevant that Professors Jarman and Bosanquet have shown how little progress has been made in the 10 years up to now. That is surely a good enough reason for delaying wholesale closures until the new services are in place.

Another approach which could be both quicker and cheaper is to base on the hospitals and their outreach centres a good part of the new primary care services that are needed. I have already mentioned the accident and emergency departments. In a new form they could be part and parcel of a new primary care service, tailor made to meet the special needs of inner London. Tomlinson himself makes favourable mention of GP projects at King's College Hospital and at the Lewisham Hospital, which is linked with Guy's, where GPs have moved into the accident and emergency departments to undertake some of the GP-type work which those departments see every day and night. Tomlinson does at least recognise the value of that initiative and how particularly important such an approach could be as a means of improving the education and training which future GPs receive in teaching hospitals.

Another good proposal is that an extended health centre should be set up on the Smithfield site—but, unfortunately, after Bart's has closed. That could be most valuable, but it would be much more effective and valuable if it was linked to a hospital which also remained on the site. I should like to associate myself with what has been said by noble Lords about the case for not closing the buildings at Bart's at least until a great deal more preparation has been undertaken.

The larger case against the Tomlinson proposals is that the new financing arrangements for hospitals have hardly got going yet. Much is obscure. A great deal more work surely needs to be done on the costing of treatments before anyone can be sure what is happening or should happen. Tomlinson was, as most people admit, extraordinarily short of vital figures on which to make a good judgment. It would surely be better to wait until there is more experience and the Department of Health has more evidence about the way its reforms are bedding down before drastic and irreversible decisions are made. Surely there should not be summary executions before the new financial system has been given its chance to show what it can do and before the hospitals' proposals for adjustment and for saving money have been given a fair and decent trial.

5.18 p.m.

Lord Peyton of Yeovil

My Lords, my first reading of the report led me to believe that the Government, unaccustomed as they ordinarily are to haste, had put undue pressure on Tomlinson to get on with the job. Many of the comments contained in the report appear to be evidence of lack of time and opportunity to look into the details more carefully.

One misfortune resulting from the time limit imposed in such debates as this is that I cannot spend as much time as I would wish either in thanking the noble Lord, Lord Annan, or in congratulating my two noble friends and the noble Lord, Lord Spens, on their admirable maiden speeches. One also tends to focus on those areas of the report which give one grounds for unease rather than on applauding the parts with which one agrees.

I would like to concentrate my remarks on three particular hospitals. Perhaps I can be forgiven for saying that to all three the charitable foundation of which I am chairman has given, and continues to give, substantial support. They are the Royal Marsden, the Royal Brompton and the Charing Cross. The first two are undoubted centres of excellence. They enjoy a world-wide reputation for both the clinical and the research work which they carry out. Bearing in mind the horrors of London navigation, they are comparatively easy of access. Huge and costly improvements have been carried out in both.

In saying what I am going to say now, I mean absolutely no reflection upon, or criticism of, the work carried out at the Charing Cross Hospital. In so far as I am aware of it I think it is excellent. But it is a fairly horrible building on an inaccessible site. I know not who the architect responsible for it was, but every time I go there I reflect upon its defects.

The idea of uprooting those parts of the Royal Marsden and the Royal Brompton that can be moved and squeezing them, or as much of them as there is room for, into Charing Cross is a notion of nightmare quality. I very much hope that the Government will drop the idea. Centres of excellence are not frequent phenomena in our country today. To persist with the move would involve not only a loss of beds, but a huge cost—the cost not only of moving but of what would inevitably be left behind. There would be damage to morale and to reputation. There would be immense disturbance and concern to patients. There would be —I believe that this should be mentioned—profound disappointment and unease, to put it mildly, on the part of those who had made tremendous efforts to raise money and who had given substantial sums. I hope that the Government will not dismiss that matter lightly because more and more, it seems, patients are going to be dependent upon charity in our hospitals.

If the Government persist with what is to my mind a very ill-conceived notion, there will be no magic adhesive available to bind together into a new coherent unit the three units they will be putting together which have such disparate backgrounds. I repeat that to take them away and put them into that building on that site would be folly.

5.24 p.m.

Baroness McFarlane of Llandaff

My Lords, I wish to add my thanks to the noble Lord, Lord Annan, for giving us this opportunity for debate in the very short period of consultation that we have so that we can voice our support for the Tomlinson Report and our reservations and concerns. Many of us in this House have a sense of déjá vu, having lived through various reports. I served on the Royal Commission on the National Health Service which reported in 1979. To this day I recall interviewing general practitioners from London and visiting, with horror, some of their premises. At the end of that report we recommended that there should be an inquiry into health care in London and that it should be conducted with some urgency. I have a sense of satisfaction that after 13 years we now have a report.

I add my congratulations to those of many noble Lords who have already spoken before for the very positive suggestions in the Tomlinson Report. I welcome the recommendations of the report as they affect primary care facilities for general practitioners. It contains innovative suggestions for the expansion of primary care; the need to test alternative models of primary care that suit the needs of London; and suggestions for extended access and availability of service.

But I have reservations. I must add my name to the list of noble Lords who have questioned the database from which conclusions have been drawn. This has been emphasised many times in this afternoon's debate. I should like to give just one example. The estimate for funding the changes in primary care as given in the Tomlinson Report is £140 million. The estimate given in the King Edward Hospital Fund report, Health Care in London, 2010, is £250 million. That leaves me with no confidence about what has been costed, what has been left out and what is the timescale.

Secondly, I believe that the report is weak on the nursing implications. I believe that district nurses, health visitors, practice nurses and nurse practitioners will play a key role in the provision of primary health care in London. There is, however, no indication of manpower requirements and the desirable skill mixes.

It is perhaps a pity that we have to await a separate report, promised last month, to see what the implications might be for community nursing, and we cannot include that in our total purview of the report.

We have to remember that district nursing services, for instance, in London cost 11 per cent. more than they do elsewhere. But there are fewer district nurses per head of population. Non-London inner deprived districts employ nearly 50 per cent. more district nurses than their inner London equivalents, and the national average is some 23 per cent. higher. Not only that, but the recruitment of district nurses and health visitors from the four Thames regions has fallen, with 12 per cent. fewer health visitor students and 21 per cent. fewer district nurse students in 1990–91. This seems to be no way to pave the way for improved primary care.

Thirdly, I want to look at the rationalisation of hospital provision, and in particular at the work of St. Bartholomew's Hospital. I have a vested interest, because it was there that I trained as a nurse.

The particular claims of St. Bartholomew's Hospital were so eloquently put by the noble Duke and by the noble Lord, Lord McGregor, that I have no need in the short time available to reiterate them. But I want to pull out some of those features of excellence in that place—and I stress excellence, not elitism—that seem particularly to apply to the objectives that we now have in the National Health Service. There are the newly opened Wolfson Institute of Preventive Medicine, the one and only institute of its kind in the country; the William Harvey Research Institute, headed by a Nobel prizewinner and in the forefront of international research into cardiovascular diseases; the only professor of paediatric oncology; a professorial department of general practice spearheading the kind of innovative changes needed in inner city areas; and a leading centre for the treatment of HIV and AIDS. I believe that that cannot be lost. We cannot pick up an institution and place it down elsewhere.

For me health care is not a game of Monopoly in which, by the toss of a dice, one is told to go to Charing Cross or to Whitechapel, or to get caught in an isochrome on the way to casualty. Health care is about caring for each other not only in contract and in charters but in covenant.

5.30 p.m.

Lord Elton

My Lords, the report appears to us to be looking at the heart of the National Health Service. But it looks like that to others too. Indeed, in an important sense it is the heart of the National Health Service. Clinical research is recognised not only here but worldwide to be a principal strength of the service and its hallmark. In that it is still a world leader. No less than half of all that research is done in London.

The impact of that research is enormous. The first product is, of course, a steady improvement in the care and cure of patients. If that were the only result it would still be necessary to maintain and to protect that effort. But there are others. British primacy in that work is, for instance, one of the most important factors in securing to our pharmaceutical industry exports which, at £2.6 billion, represent 3 per cent. of all United Kingdom manufacturing exports. That creates jobs and stimulates the economy wherever in the country the industry and its supplies are based. So this is one of the rare occasions when it would be reassuring rather than the reverse to know that the Treasury will be involved. Will the Minister tell us, please, how the Treasury will be involved and what cost-benefit analysis will be made?

The economic benefits of clinical research do not end with exports. Other effects are noticeable here in London. The primacy in this field, not just of Britain but of London, is recognised worldwide. That is a powerful magnet. Patients come to London from all over the world. Most go to the private sector but they do so because of the work in the public sector. They come here, they are treated and they pay. Their families come here and stay in our hotels. They buy our goods and they pay too. The benefit of that to the economy of greater London alone is about £1 billion per year.

As there is now no widely-recognised body to voice the interest of London as a whole in this consultation, will the Minister tell us whether a copy of this report has been sent, with an invitation to comment, to the London Forum? That body was recently founded for this purpose under the chairmanship of Sir Alan Shephard. If not, would she please arrange for that to be done?

The benefits do not end there. Doctors, trained here at a balance of payments benefit of £5.5 million per annum, carry home not just their skills but their experience. They have experience of British practices, British institutions and British products. In that strictly non-colonial sense trade still follows the flag. Our role in clinical research is a vital factor in the achievement of that £2.6 billion of pharmaceutical exports.

We do not have the job of training those people as of right. It is not some easily retained legacy from our imperial past. We maintain it in the face of real and increasing foreign competition. We shall keep it only for as long as we remain a leading first world country in terms of clinical medical research. It is clear, is it not, that clinical research is good not only for the health of the nation but for the wealth of the nation as well? It must therefore be sheltered in the impending process of change because what we are dealing with is not a mechanism but an organism—and a symbiotic organism at that.

Clinical research, as the noble Lord, Lord Desai, pointed out, requires the security of supply of patients over a period of years in a highly-specialised environment, supporting collaborative multidisciplinary teams. It takes not years but decades to build those teams. If they are broken up specific and costly provisions will be needed to repair the damage. That in itself dictates a steady not a precipitate programme. Will my noble friend please remind the Treasury that, if it pursues short-term savings to the exclusion of long-term gains, it will for that reason kill the system altogether?

The debate on how SHAs are next to be funded is critical but it may be premature. Following your Lordships' Select Committee Report in 1989 Professor Michael Peckham set up within a new unit in the Department of Health a review of NHS-funded research. That debate cannot be properly conducted without knowledge of his work. Is it now available and if so where? If not, will my noble friend please tell the House how and when it will be brought into the current consultation process?

Paragraph 87 of the report refers to the overhead cost of SHA research as "notional". That word has two current uses; one conveys that the figure is not reliable and the other that it does not matter. In which sense do the Government take that word? Neither seems to be appropriate. The figure is generally thought to be about half the costs of SHAs. That is not significant, nor must it rest on uncertain calculations. The urgent need now is to obtain a firm costing. That will be critical to the viability of competition between the SHAs, or their successors, and other providers in the NHS market. I follow the noble Lord, Lord Annan—whom I have time to thank warmly for introducing the debate so eloquently and elegantly —in saying that to lose the sum in general capitation, as is proposed, would be to cast aside the only means so far established of securing a competitive and therefore viable clinical research sector in the United Kingdom. If it is not viable we shall lose all the advantages that flow from clinical research. Will the Government please proceed with very great care?

5.37 p.m.

Lord Smith

My Lords, we are all greatly indebted to the noble Lord, Lord Annan, for introducing the debate. The subject is of wide public interest and is of great concern to all health workers, in particular doctors. I am a surgeon but during my early professional years while working for my final FRCS degree I was a general practitioner in London. Therefore, I have limited experience in the primary care of patients as well as consultant care in hospitals.

I am in favour—I believe that all doctors are in favour —of improving the standard of the primary care of patients in London. Nevertheless, the Tomlinson Report implies that we can best do that at the expense of the hospital sector. If we pursue that course we should proceed with much care and circumspection and we should look askance at some of the recommendations in the report.

The closure of hospitals would, in some cases, inevitably lead to the breakup of clinical teaching and research teams. The money available would not necessarily be spent on primary care. Much of it would be spent on redundancies and on reshaping what hospital services would remain. Doctors are not obstructive to necessary change but we must support some hospitals. I should have thought that any government would have done much to avoid going down in history with a stigma for abolishing Bart's. But I am not a Bart's man. Improving primary care is a worthy objective in itself, but it must be managed without seriously affecting the fundamental effectiveness in hospital treatment; otherwise, we should in truth be losing the baby with the bath water, because primary care is a mere preliminary to hospital care in severe illness. Nevertheless, the Government will have much support if they aim to improve the lot of general practitioners. But it will not be easy or inexpensive.

Time is short and I can but summarise the considerations which I believe the Government should at least take into account: the provision of health centres; the mobility and transport of doctors, nurses, technicians and equipment for home care; provision of beds for patients of general practitioners; specialist visits to patients' homes. All those factors must be individually considered.

I close my remarks by referring briefly to research in general practice. Primary care must include research into the wider implications of the cause of ill-health. There is no doubt that poverty, bad housing, unemployment and poor education must be factors, and research in primary health care should be invaluable.

I wish the Government well in this most difficult task of trying to improve upon the primary care of patients in London. I believe that major additional funding must precede any hospital rationalisation programme. We must not devalue the fundamental clinical teaching and research teams which have been built up over the years at our teaching hospitals, which are the best in the world.

5.41 p.m.

Lord Jenkin of Roding

My Lords, one theme has run through the Tomlinson Report and many of the speeches that we have heard this afternoon; namely, the need to improve primary care and community health services. In introducing the debate the noble Lord, Lord Annan, stressed primary care but I add always the words "and community health services" because they are as important in the delivery of health care as are the general practitioners whom one normally recognises in primary care. That has been widely reflected in the speeches this afternoon.

Although there have been criticisms of individual recommendations, there has been broad support for the thrust of the Tomlinson Report. I have said to my right honourable friend the Secretary of State that I believe that with this report she has the wind in her sails in a way that no previous report covering the reform of the health service in London has provided.

As regards the Acheson Report, I should say to the noble Baroness, Lady McFarlane of Llandaff, that I implemented that Royal Commission recommendation when I appointed Sir Donald Acheson and he did report, albeit to my successor and not to me. It is right that his recommendations should have been picked up by Tomlinson.

At this stage of a debate one does not wish to repeat generalities. I should like to single out one aspect on which I do not believe Tomlinson has recognised the truth of the need to focus services on the community and on primary care. That is referred to at paragraphs 48 to 54 of the report dealing with integrated trusts. Tomlinson has come down very firmly against trusts being responsible both for acute hospital and community health services. I do not believe that in this he has followed the logic of the main thrust of the report.

I have referred previously in your Lordships' House to the Forest Health Care Trust, of which I have the honour of being the chairman. It is a whole-district, integrated trust. We have abandoned what I call the Tomlinson model, which has a very firm door at the hospital that separates the community services, on the one hand, and hospital in-patient care, on the other. Our management cuts right across that. Care is concentrated on the patient—on patient care groups, with the managers, clinical directors and teams of doctors and nurses straddling what I describe to my managers as "the seamless robe" between acute care in the hospital and care in the community and support for general practitioners.

It seems to me—and I pick up what a number of noble Lords have said—that we should not choose one single model because in inner London that model has been shown to be deeply flawed. I am sure that Tomlinson is right that where there is that separation, the strength of the teaching hospitals has been to suck in resources to the detriment of community health services. That is perhaps the most important single thing which Tomlinson said. However, that does not necessarily mean that there must be separate management. On the contrary, everything is to be said for a unified management provided that it is absolutely clear what one is trying to achieve.

Our purchasers wish to see more care in the community and strengthened primary care. Therefore, as a provider—and Forest Health Care Trust is a provider—that must be at the heart of what we are trying to do. I have here example after example of how, because we are managing people and managing resources as a single team across the whole spectrum of the service, we are now switching care into the community. We have had to trim back acute care on non-urgent operations in order to fulfil our statutory duty to break even. Even so, we are switching another £0.25 million into community care.

As the noble Lord, Lord Young of Dartington, commented, we are working to get GPs into our accident and emergency units. Consultants are beginning to give out-patient treatment in health centres. We are beginning to have community paediatric teams which work both in the hospital, in the children's wards and out in the community. A midwife is attached to the patient in the primary care sector in the community and the same midwife works in the hospital. We can do that because it is all under the same management. The same is happening with geriatric services. That has greatly improved the discharge arrangements and the transfer of patients from acute to longer stay care and eventually into the community.

Therefore, I find it absolutely astonishing that faced with all that—and we gave evidence to Tomlinson about it—Tomlinson still recommends strongly that the integrated trusts should be unpicked. He says, perhaps in obeisance in our direction, that perhaps in outer London the arguments are not quite so strong. The arguments are strong for an experimental approach, a variety of solutions, and in particular for our solution which manifestly is seen to be working well and has the support of the local medical committee, the GPs and our purchasers. That work should not be unpicked in trying to go back to the closed door between acute and community services. That is what Tomlinson is about. If my noble friend or her honourable friends try to unpick me, I shall be very cross indeed!

5.49 p.m.

Baroness Masham of Ilton

My Lords, one of the greatest weaknesses in the Tomlinson Report and that of the King's Fund is that there seems to be no user-patient input. I should like to quote from a letter that I have received from the Lane-Fox Respiratory Union Patients' Association at St Thomas's Hospital: As with all people concerned with the main London hospitals our members are concerned at the outcome of the recommendations when the report has been considered by the Ministers". I hope that the Minister's advisers will be unbiased and honourable.

I hope that the Government do not rush into taking action which they will deeply regret when it is too late. I had my life saved in a specialised centre of excellence. I saw, first hand, patients who were eventually referred to other hospitals because district general hospitals had made a mess. In the long run, it is to the benefit of all that the GPs and hospitals which do not know how to proceed further with an acute patient's treatment can refer patients to specialised units in order to receive advice from them.

For research purposes to progress and develop new treatments and to combat some of the life-threatening conditions which take away so many of our dearest friends and children, one must have enough patients and congenial working conditions to attract the highest possible research workers. It is not only in London that there is anxiety in the research world. I have a cousin who is a research doctor in Leeds. In a letter he recently wrote to me, he said, It has not been a particularly pleasant experience answering to two institutions (university and hospital) that hold two conflicting sets of priorities. Clinical services are deteriorating, promising research projects are losing their momentum and the teaching commitment goes well beyond reasonable limits. Small wonder then that I am considering an offer from the University of Singapore—I would honestly prefer to stay in Leeds if at all possible, but I fear that the current environment is becoming increasingly hostile to the combination of service ethic and clinical leadership for which I have trained". It will be a great loss if we lose our up-and-coming doctors to countries which can offer them more job satisfaction and appreciation.

I hope that the Secretary of State will not go along with some of Tomlinson's suggestions, otherwise there will be demoralisation of and indignation from many people. I witnessed the sheer disbelief on the faces of some of the people who raised £2 million in these difficult times to upgrade the world-famous Royal Marsden Hospital when they heard that it was on the "hit list". It seems madness that the new Royal Brompton National Heart and Lung Hospital, opened last year by Her Majesty the Queen, may close. It has special catheter laboratories next to the theatres, lead-lined walls built around the hi-tech equipment and special copper-lined walls for the magnetic resonance unit. There has been expertise training for the medical, nursing and technical staff to work in such a critical and specialised hospital.

Last but not by any means least, one of the best known and much loved hospitals which is the oldest in London—founded in 1123—and which has served the poor free all its life, is St. Bartholomew's. It was founded in a spirit of service and giving. It does not serve only the local catchment area. With its expertise in leukaemia and other complex conditions it serves the whole country and is world renowned for its medical school and excellent nursing school.

Surely this Government cannot be responsible for the destruction of one of our heritage gems with the best tradition of care which has been passed down from generation to generation of doctors and nurses. That inheritance cannot be picked up and put down in some dreary modern block. Part of the history lives in the aura which surrounds the buildings. Bart's survived the fire of London and Hitler's bombs; can it now be closed or sold to Saudi Arabia? With modern communication the world is small and we will be thought crazy.

I believe many busy people who come up to work in the City of London and thereabouts need a good hospital that they can attend near to their place of work so that too much time off work is not taken. Have the disasters such as Moorgate, Kings Cross, the IRA City bombing and the recent air crash in Amsterdam not taught us how important it is to have highly skilled medical care with full back-up and beds easily available in a city choked with traffic? With the shadow of AIDS spreading throughout the world and increasing, as announced yesterday by the World Health Organisation, it is quite extraordinary that we should be appealing for the retention of our best hospitals when they are so often our only lifeline.

5.54 p.m.

Baroness Eccles of Moulton

My Lords, perhaps I may start by thanking the noble Lord, Lord Annan, for giving us this opportunity to debate the Tomlinson Report and also to add my congratulations to those already made on the excellent maiden speeches we heard this afternoon. As chairman of an outer London health authority I am particularly interested in how the recommendations might affect the outer London ring.

It has been said many times already that we are at a stage when the pressure for change in London is great and that will intensify as the effects of capitation funding and the internal market take hold. It would be wrong to imply that no efforts have been made to adjust the imbalance between London and the rest of the country before the concept of money following the patient was introduced. Before reform-stimulated information was available, the Thames regions knew that there was a distortion in funding between London and the Shires, and the Resource Allocation Working Party, better known as RAWP, was an attempt to adjust the imbalance. No doubt it has helped, but it is necessary to get at the cause.

The cause has two main features which are interrelated. As has been stated many times, in central London there is inadequate primary and community care, both in quality and quantity, and too many high-cost low-volume hospital beds for the population it serves: I had a lot more to say on that but I shall move on. It has been clearly demonstrated that improvements must be made in primary and community care in order to reduce the inappropriate use of hospital beds; that would include more nursing homes to relieve acute beds that are being used at present mainly for social care. Because of circumstances peculiar to a great inner city, innovative and imaginative ways must be found. The solution cannot be confined to bricks and mortar, important though they are; initiatives are needed from doctors across the spectrum to discover new and different ways of providing the service. The Government may also have to look at innovative ways of funding the transition.

First of all, there will have to be investment in improved primary and community care which will reduce the demand on beds. There will also need to be found funds covering the costs associated with amalgamating hospitals—assuming, of course, that the recommendations are implemented. Then there will be a time lag before the payback of lower overheads in the acute sector and potential capital receipts can be realised. Therefore one solution may be a capital pool out of which bridging arrangements could be made.

What of the effects on outer London? Faster throughput and more day case work—both the result of progress in medical technology and both incidentally better for the patient—are resulting in falling acute bed demand in outer London. Although the move to weighted capita funding is not yet complete, health authorities are entering into contracts on behalf of their resident populations and seeking to get the best value for money at the highest standards possible. Inevitably there is a substantial move away from contracts with high cost London teaching hospitals for treatment that can be carried out at lower cost nearer home. There is a high degree of support from both patients and GPs for this policy as hospitals in outer London now have better facilities and a wider range of medical expertise than used to be the case.

As the effects of the Tomlinson recommendations bite, the results will be patchy in different parts of outer London depending on the effects of patient flows, existing outer London specialties, the scope for development and so forth. A big impact would be the closure of a nearby accident and emergency department and the effect it would have on the work load of neighbouring hospitals.

The greatest benefits that the outer London ring will receive from a rationalisation in Inner London is in funding and inpatient access. As we well know, last year's funding included a generous amount for growth in the funding round. Too much of that was soaked up in keeping the big, expensive teaching hospitals going and there are many statistics to support that. There is so much that we can do to improve the services, again with emphasis on primary and community care. In particular, our new partnership with the local authority, which will take effect next April, very much increases the need for all health moneys to be used economically and effectively.

The public is our severest judge wherever we work. However, judgment will tend to be set against traditional patterns of service with bed numbers writ large. We have much to do to build public commitment to an emphasis on primary care and family health services. We must make sure that real service benefits are achieved.

6 p.m.

Earl Russell

My Lords, I would like to thank the noble Lord, Lord Annan, for introducing this debate. As an employee of the University of London, like an employee of the European Community, I must declare not one interest but many. Since in 27 years as a Londoner I have also had a variety of needs as a patient, I am tempted to wonder whether perhaps I have so many interests that I might become impartial.

As the noble Baroness, Lady Masham of Ilton, put it, a teaching hospital is two conflicting institutions with two conflicting priorities. It is both a university and a hospital. A teaching hospital is in fact like a centaur; it cannot be adequately fed on a diet which consists of nothing but oats. In 1989 we introduced a system with the purchaser-provider split and money following the patient. That is the system of disbursement. That conflicts with the needs of teaching and research which are essentially needs for concentration. Excellence is well-known to feed off other excellence and to benefit from being concentrated in one place.

Nobody—least of all an academic—should argue that the needs of research should automatically be paramount. The new system has come in and it would be foolish to think of reversing it. I wonder whether quite enough thought has been given to exactly how the balance should be struck because, although we cannot give primacy to the needs of teaching and research, I do not believe that we should ignore them either.

We are getting something in the region of £1 billion a year from overseas patients and about £12.4 billion a year from related income from the pharmaceutical industry. That is serious money. I believe that Dr. Malcolm Green is right that a top London hospital is not only concerned with patient care. The Tomlinson Report, considering almost exclusively patient flow, has not necessarily got the whole picture, although it has got a very important part of it.

The report talks constantly about mergers. I listened with a great deal of agreement to what the noble Lord, Lord Carr of Hadley, had to say about them. I have some experience of mergers in the University of London. If one thing is clear about them, it is that the costs are certain and the savings are uncertain. Some of your Lordships may have read the recent correspondence, which is still continuing this morning, about the sale of the pictures at the Royal Holloway & Bedford New College. That does not result from academic vandalism, but from an under-funded merger. That is a story that may be repeated.

I agree strongly with what the noble Baroness, Lady McFarlane of Llandaff, said about breaking up teams. Emigration has been mentioned. I have emigrated myself. It was not just to avoid a merger. However, I admit that the thought of being moved out to Egham entered into my calculations. So this is not a matter to be dismissed altogether. The foundation of evidence on which the Tomlinson Report relies is not perhaps of the thickest. The report itself states at Paragraph 110: Our analysis of the vulnerability and natural catchments of the main inner London hospitals is fairly crude". For example, the conclusion that the West Smithfield site is inevitably to be run down seems to be produced like a rabbit out of a hat and I cannot really follow exactly what the conjurer has been doing in the paragraphs immediately before.

Above all, I agree with what the noble Lord, Lord Carr of Hadley, said about costs. There is also a slightly selective use of evidence which tends to underrate the excellence involved. The UFC rankings are quoted in a slightly selective way. One would not guess that two out of the four highest-ranked medical schools in that ranking exercise are in London.

But, above all, it is the cost point which matters. The noble Lord, Lord Carr of Hadley, said that, if we have not got the money to meet the costs, we should not start. Even if we agree with the noble Lord, Lord Hayhoe—whose maiden speech I listened to with great pleasure—that the status quo is not an option, that should be said with the qualification which the noble Lord, Lord Carr of Hadley, put on it. If we do not pay for the reorganisation it will be a mess and then we shall lose something which should not be lost.

6.6 p.m.

Baroness Seccombe

My Lords, perhaps I may first declare an interest, but not a financial one. I am a governor of Nuffield Hospital. I should like to add my thanks to the noble Lord, Lord Annan, for initiating this debate. It gives us an excellent opportunity to discuss this important report which has been so eagerly awaited.

Our National Health Service is quite rightly regarded with great affection in Britain and it is very much respected abroad. Just as the NHS has set standards in health care for the world, so often have London's health services within it. The capital's health service has, over the years, trained thousands of NHS staff to the highest standards. It has been at the forefront of research. As professionals, its staff have always adapted well to changing circumstances and to new opportunities.

Less than two years' ago the health service was subject to wide-ranging reforms. Since that time those working in the London NHS have responded well. In fact, in the four Thames regions the number of patients waiting over a year for treatment has fallen by nearly 35,000. In those regions the number waiting over two years has dropped dramatically from more than 20,000 to just 5,000 since the reforms were introduced. I am sure that the whole House will acknowledge that these achievements are testimony to the hard work of hospital staff in London and the surrounding counties.

We can also acknowledge the recent improvement in family doctor services in the capital. Under the system of deprivation payments introduced as part of the GP contracts, the greater demands and needs of patients living in deprived areas are now beginning to be met. More inner city practices are reported to be meeting their targets for cancer screening and immunisation.

People living in a city which has contributed so much to health care should be able themselves to rely on top quality services provided by family doctors or within the community. Although less glamorous than some of the treatments provided by the teaching hospitals, these services are no less essential. London's population and its requirements have changed over the past 50 years and the capital's health services must adapt accordingly. There now appears to be something approaching a consensus that, as a result of these long-term trends, a disproportionate amount of London's health resources are spent on hospital services. That was the conclusion of the Tomlinson Report and it is one which is shared by many others.

A reduction in the proportion of NHS resources in London which is spent on hospital services would free money for further improvement in primary and community care. The report also presents an opportunity for these sectors to work much more closely together, providing a continuation of care tailored to the needs of the patient; and more consultants to visit health centres in the community. It is pleasing to see that some fund holders are encouraging them to visit their surgeries. Meanwhile, GPs could assist in accident and emergency departments.

The first official report which concluded that London has too many hospitals was published in 1892, and now it is 1992. Consultation is important, but even by civil service standards I think that after 100 years the period for reflection may well be nearing its end. The time for reform is now approaching. I believe that London's NHS will adapt well to such reform. The ability to do so is a characteristic of all great institutions, and the principles contained in the Tomlinson Report will fashion an NHS in London which looks forward to the future and not just back at the glories of the past.

6.11 p.m.

Lord Cocks of Hartcliffe

My Lords, I too should like to thank the noble Lord, Lord Annan, for giving us an opportunity to discuss Sir Bernard's report. Perhaps I might take as my text a phrase which he used: Where is the money to come from? It is a phrase which is frequently heard in political circles, but basically this debate is about resources and how they are used. My noble friend Lord Dean has already drawn your Lordships' attention to the scandal of the Wessex computer system and the millions of pounds that have gone down the drain there. It is terribly important that while we can kick concepts and ideas about we have the financial resources to buttress action.

Sir Bernard's report refers to the disposal of a number of sites. On 10th November I had a Question answered by the Minister who is to reply today. I asked her what valuations of sites and buildings were made during the preparation of the Tomlinson Report and what was the date of those valuations. The reply was: I understand that, in preparing his report, Sir Bernard Tomlinson took into account information about the NHS estate in London from a number of sources, including the NHS Estates Agency, the Valuation Office Executive Agency, the Thames regional health authorities, the King's Fund Working Paper No. 11, and individual hospitals". It is not exactly crisp and to the point in relation to what I actually inquired, but I do not complain about that: I have been in the trade myself in the past. Perhaps it was the normal civil service caution and possibly they might clutch to the bosom the excuse of commercial confidentiality, or possibly the valuations which were done earlier might be rather embarrassing compared with the valuations done later. The noble Lord, Lord Hayhoe, whose speech I much enjoyed, referred to the collapse in land values. The same point was made by the noble Lord, Lord Carr, when he referred to the present state of the property market.

In paragraph 227 of the Tomlinson Report, when referring to NHS capital disposals, Sir Bernard says: during the transitional period of reorganisation … the suspension of the presumption that the proceeds of assets disposals should remain in the hands of the trusts concerned. Such disposals should normally be seen as windfall capital gains, and should be recycled for the benefit of the reorganisation of the NHS in London as a whole". My understanding of "windfall" is that it is something which comes unexpectedly—and here I must say that my understanding is purely theoretical, I am afraid. But I should like to know just how much reliance the Government are building into their financial calculations about the income from disposals. Is it all now nicely stitched up without any income from disposals? Is it just "bunce" or is it an integral part of the calculations on which these changes are based?

The Government have introduced their own joker into this pack because we are now to have a register of contaminated land. There is a great deal of concern in property and development circles about this because of the blight which might be attached to areas. In fact it has come to light recently that the Department of the Environment in Marsham Street is built on the site of an old Victorian gasworks. I will not make any obvious comments about this as time is too short, but the noble Duke, the Duke of Gloucester, pointed out that superimposed on any possible contamination of sites is the question of whether buildings are listed. He went into some detail about the unsuitability of Bart's Hospital for any other purposes. That was buttressed by evidence to the Government which has been submitted by the special trustees of Bart's and St. Mark's Hospitals after the publication of the report. It applies elsewhere. The question of archaeological remains is always pertinent in London. We never know when the clammy hand of English Heritage is going to stretch out and someone is going to say that some particular vestige has got to be kept for posterity.

Therefore, it must surely be totally unrealistic to expect any very substantial financial benefit to implement these proposals from the disposal of existing assets. I raise this point now because I do not want to sit here in years to come, witnessing some hand-wringing going on and voices saying, "If only we had known". Let it be quite clear that not only I but other speakers have raised this point with the Government and that we will not in any future discussions on this matter listen to the excuse, "Well, of course, these were unforeseen circumstances".

6.16 p.m.

Baroness Cox

My Lords, I too thank the noble Lord, Lord Annan, for this timely opportunity to discuss the changes confronting health care in London. I deeply regret that I will have to leave before the end of the debate due to a longstanding commitment. I shall read with great interest the contributions it will be my misfortune to miss.

I must declare two interests. I serve on the board of the West Lambeth NHS Community Care Trust and I am a vice-president of the Royal College of Nursing. In both capacities, I and my colleagues welcome the proposals designed to bring about a reorientation towards more resources for primary health care in London.

There is inevitable anxiety about the future of specific institutions and of individual posts, which merits sensitive attention. But many of my colleagues support very strongly the general principles and premises of the Tomlinson Report, which are consistent with the general conclusions of the King's Fund Report published in June. They accept the analysis that too many teaching hospitals are serving a declining population, that there is a duplication of expensive specialist departments and that resources have been diverted away from local hospitals, general practitioner and community services.

Speaking from my experience in West Lambeth Community Care Trust, I have great confidence in the ability of staff in the community to rise to the challenge of changing health needs and to adapt local health services accordingly. For example, responding to the increase in the numbers of confused elderly people suffering from Alzheimer's disease, Lambeth has established a night respite care centre. The demands of caring for a confused, elderly relative put great stress on families, and constant lack of sleep is one of the most frequent reasons for families requesting a relative's admission to residential care, often with great reluctance and feelings of guilt. But Lambeth's Crest Night Respite Centre has helped many families to keep their elderly relatives living with them at home. This initiative is care effective and cost effective: it is one example of the imaginative ways in which health professionals in the community are responding to the changing needs of the populations they serve, reflecting that theme of the need for innovation which was mentioned by my noble friend Lady Eccles.

In West Lambeth Community Care Trust, morale is generally very high; and although there are formidable challenges, staff in all grades of service—medical, nursing and paramedical, and in vital areas of service such as those serving in laundries, kitchens, transport and communications —are all responding magnificently to the new autonomy and developing numerous initiatives, which enhance the quality of care they provide.

However, there are inevitably some anxieties. The first is over the timing of the allocation of resources. It is imperative that the Government invest in staff and facilities in primary and community health care services before the transfer of responsibilities, in order to prevent a hiatus in which some of our most vulnerable people would suffer. There is a need to invest in the most precious resource that the National Health Service has: people.

Perhaps I may especially highlight some of the problems confronting nurses. They are the backbone of care both in the hospitals and in the community. Hospital-based nurses should not be seen as surplus to requirements and made redundant. They should follow, where possible, patients and clients into the community. But community nursing requires different skills from hospital nursing. There is therefore a need for carefully planned education programmes on a pan-London basis, rather than on the current regional basis, which is causing problems in inner London as the regions are not co-ordinating their policies.

The Royal College of Nursing's report, London Needs All Its Nurses, endorses the proposals for the shift to the community but emphasises again the need for adequate funding. For example, there has been a serious decline in recruitment of community nurses in London, with a drop of 21 per cent. of district nursing students between 1990 and 1991, because health authorities have reduced sponsorship. This is especially disturbing when the workload of community nurses is increasing, and when there are opportunities for the development of exciting new roles, such as nurse practitioners, so ably advocated by my noble friend the Minister in a previous incarnation.

In conclusion, I ask my noble friend two questions. First, the Tomlinson Report recommends a total review of weighted capitation. This is critical. The current formula does not take adequate account of key issues such as homelessness, quality of housing, numbers of people suffering from HIV or Aids, drug abuse, and so on. An area such as Lambeth has some of the highest indices of social deprivation and health needs in the country. We therefore urge that the review of the system of weighted capitation be accepted. I should be grateful if my noble friend the Minister could give reassurance on this.

Secondly, and finally, can my noble friend give assurances that the allocation of resources to primary and community healthcare will be made, and made in time, so that the generally very welcome proposals of the Tomlinson Report will be implemented in ways which achieve their objectives of providing more and better health care in the community at the point of need to the benefit of all concerned: patients, clients, families, and the dedicated staff who serve them.

6.22 p.m.

Lord Dainton

My Lords, I fear that I cannot go as far back in time as the noble Baroness, Lady Seccombe, but the problems of maldistribution of health care provision within the four Thames regional health authorities, and especially inner London, are longstanding. Eighty years ago some of the clearest perceptions of London medicine came from outsiders like the young Yorkshire doctor turned politician, the progressive Christopher Addison, who gave us National Health insurance, and the distinguished American medical reformer, Abraham Flexner, from Johns Hopkins University.

I confess that I too am an outsider. I am not even a doctor, but from my past experience as chairman of the UGC trying to build up the numbers of medical students in London and trying to couple, if that is a not an inappropriate term, medical schools under the beneficent parentage of pre-clinical training afforded by multi-faculty institutions, I am afraid that I am inclined to share some of the scepticism of Addison and Flexner when I hear the not infrequent claims for the uniform excellence of London medicine.

Seen from my experience and vantage point, and from the excellent report of the King's Fund that has already been referred to, I have no doubt that the Tomlinson Report is correct in its diagnosis of the London problems and in the general thrust of its proposed changes. The present balance between primary care and specialist acute facilities is tipped far too far in favour of the latter and is especially inappropriate to inner London's needs. That must be rectified.

The proposals for merger of the undergraduate medical schools and their clustering in multi-faculty institutions, with the exception of St. George's at Tooting, are clearly sensible. No one should stand in the way of those changes, at least in principle, although I do not consider that the case has been made for the recommended reduction of the medical intake by 150. In any case, the issue of medical student entry seems to me of much lower priority for implementation than many of the other recommendations.

There is a strong case for the question of student numbers to be further studied by the implementation group, which should certainly be established as quickly as possible by the Secretary of State and which should have as one of its members a person who is knowledgeable about the University of London. That university has an extremely important place in medical education and research in this country. Those activities are bound to be much affected by changes in the provision of hospitals. It has occurred to me that perhaps the present director of research in the Department of Health, who was formerly a director of the British Postgraduate Medical Federation, would make an admirable member of the committee. It is obvious that if teaching hospitals are closed because of reducing numbers, then both teaching and research space will be lost.

In that context I should like to make the general observation that there is always a danger that the "planners", with their minds focused on better health care today, can, in the course of executing their reforms, almost inadvertently remove the infrastructure so essential to good research and teaching; an infrastructure which, once destroyed, is so difficult to replace. Those planners should remember that the medical research community have had to endure and accept many changes in recent years, and that those changes have inevitably affected the morale and commitment of able research scientists. If any further changes are called for, and I expect they will be, they should only be arrived at and managed after the widest consultation not only with the leaders of those scientists but with the Medical Research Council and with the major medical research charities.

That brings me naturally to another feature which is peculiar to London; namely, the dedicated postgraduate clinical research institutes of the University of London and the Royal Postgraduate Medical School—about which, as its president, I must declare an interest—and the special health authorities which are the unique channels through which the associated hospitals receive financial support directly from the Department of Health. It is in dealing with these matters that the report is least convincing, in considerable measure because the conclusions are based upon assertions largely unsupported by any accompanying evidence.

For example, in paragraph 157 it is stated: Single-specialty hospitals are, on the whole, less than ideal for patient care, and for research and teaching". That statement is not buttressed by any argument. Nor can such a conclusion be supported by overseas experience. Nor does any careful financial analysis underpin other statements.

I am of course always open to be persuaded on the assertions but only if the matter is much more carefully documented than appears to be the case in the report. In particular, if the special health authorities would, under this proposal, become trusts, then one has to think that while the special increment for teaching and research may increase their income from that source, it would still leave them with at least two-thirds of their income open to market forces. This may lead to a patient mix that is totally inappropriate to their main mission, and that cannot be right for those institutions which are in the forefront of medical research.

In deference to the eminently fair, self-denying ordinance under which we are to limit our speeches, I shall conclude simply by saying that I too hope that the implementation group will be nominated without delay, but I would add the rider that the Secretary of State should not instruct the implementation group to implement every Tomlinson recommendation as it stands, but that the group must have the right to test against ascertained facts or wide experience the validity of those recommendations which are doubtful, and have the right too to come to different conclusions.

Also as part of this deliberation, the evidence for taking any steps which would significantly change the roles of any institution must be discussed with its representatives because, at the end of the day, the quality of the service, whether patient care, education of students or research, is crucially dependent on the quality and morale of those persons who carry it out, and they will not commit themselves wholeheartedly unless they can be convinced that decisions on the organisation and funding have been arrived at on the basis of transparent, rational arguments, securely based on published data which are accepted generally as being valid.

With these reservations I would commend the Tomlinson Report as a valiant attempt by yet another "outsider" to wrestle with difficult problems in London. As the noble Lord, Lord Walton, said, the opportunity to improve medical care in London must not be missed this time, even though the management of change will be difficult, particularly that of getting the sequence of events right.

6.30 p.m.

Lord McColl of Dulwich

My Lords, I should like to add my thanks to the noble Lord, Lord Annan, for introducing this debate. I was a little surprised that he should start off by attacking the consultants. After all, it was the consultants who managed to achieve agreement on the closure of a cardiac unit in London —no mean achievement. Who was it who threw a spanner in the works? The local MP in whose constituency the cardiac unit was situated. I am also a little surprised that the noble Lord should make the remarks that he did about Bart's, Guy's and St. Thomas's. Those institutions are doing very well in furthering advances and co-operating with some of the proposals. But I ask myself who was in charge of all these medical schools. Was it not a vice-chancellor? Why did not the noble Lord, Lord Annan, himself use his power to force change when he held office?

London has by default done itself a disservice over the past 10 or 20 years by allowing its resources to be spread too thinly over too many hospitals. But slimming down all these hospitals is simply not an option because that would lead to a deterioration in patient care, teaching and research. Furthermore, it would increase unit costs which would make the hospitals even less viable. With the increasing complexity of medical care the specialties are becoming increasingly dependent on one another and they need to be situated either within the curtilage of a general hospital or grouped together closely on one campus. One suggestion made by Sir Bernard Tomlinson was that the Marsden and the Brompton and their institutes should be closely grouped together with the Royal Westminster and Chelsea Hospital. Their research could be enhanced by close ties with the nearby Imperial College.

The Government are currently putting in £50 million a year simply to make up for the overspending of the excessive hospitals in London. This money comes from the rest of the country, and the rest of the country is none too pleased with this arrangement continuing. All this means that mergers and the regrouping of hospitals in London are inevitable.

One of the problems in London is that the elderly tend to end up in acute hospitals where they stay simply because there is nowhere else for them to go. We may need fewer acute beds in general hospitals, but there must be provision for the elderly in more suitable accommodation—in nursing homes, of which London is extraordinarily short. The domination of patient care by the hospital sector has to give place to a much more rational scene with greater emphasis on primary care and community care, and a great deal of money will have to be found to do this and to build much better GP premises. Until such premises are available, I am attracted by the suggestion of my friend the noble Lord, Lord Young of Dartington, that accident and emergency departments, specially run by general practitioners, could help in this way.

Mental health services have never received the attention they need, but putting them into separate trusts will greatly improve matters, provided that the trust business plans include the hospital as a base and pivot for community links, day care and that essential ingredient, respite care.

There is a genuine worry about the recommendation that special health authorities should no longer have their special arrangement whereby their services are free to the purchasing health authorities. This is regarded by many as unfair competition which is drawing patients away from similar units in teaching hospitals whose services are not free to the purchasing health authorities. This present arrangement is threatening the viability of those units within the teaching hospitals and possibly the hospitals themselves. Tomlinson's solution to this problem is for the special health authorities to receive the same financial help as the teaching hospitals enjoy to cover the extra costs of research and teaching on their patients. With this extra payment many undergraduate teaching hospitals outside London achieve high levels of research as judged by the assessment of the universities. There could of course be a difficulty with research into rare disorders, but these could be protected, as Sir Bernard has suggested, by supplements available from central funds to any hospital with high quality research.

When it comes to implementing this report it is essential in my view that decisions should be made crisply and with no fudging. As has been said for many years, Guy's and St. Thomas's should fuse on one site. First of all, the management should fuse and then decide, on objective data, which site should be the hospital. The other site could then be used for a single academic centre for the medical schools of Guy's, St. Thomas's and the life science from King's College in the Strand, together with the school of nursing and midwifery. This would make a most attractive campus. The worst possible bureaucratic nightmare would result if the managements were to be fused and then for both sites to continue as hospitals.

Failure to implement this report would condemn all London hospitals to death by a thousand cuts. We need urgent, radical solutions to these problems in order to improve the quality of care in hospitals, in general practice and in community services. This will lead to better patient care, better teaching and better research. Sir Bernard Tomlinson's report provides the answers. We neglect them at our peril.

6.36 p.m.

The Earl of Stockton

My Lords, in thanking the noble Lord, Lord Annan, for giving the House the opportunity to debate this important subject, I must apologise to the House for being unable to be in my place for the whole of the debate, but I have a prior commitment which, as it is helping the University of Strathclyde with the development of postgraduate programmes, will, I trust, be close to the noble Lord's heart.

The Government appear to be committed to the concept of centres of excellence in their proposals to reorganise teaching and research in the inner London hospitals, as outlined in the Tomlinson report. And yet included in those proposals is the suggestion that London's, Britain's, and indeed Europe's newest and most advanced teaching and research hospital for the treatment of heart and lung illnesses should be closed and moved. The Royal Brompton National Heart and Lungs Hospital, in Sydney Street in Chelsea, was constructed to the highest standards to take advantage of the latest developments in keyhole surgery in all of its operating theatres, and already 50 per cent. of the operations undertaken use this technique. Involving as it does the continuous use of complex X-ray observation to obviate the need for traditional invasive surgery, the walls, floors and ceilings have to be constructed with the appropriate radiation shielding as part of the basic structure. You cannot just pick up such a thing and move it down to Charing Cross Hospital, where, even if such a unit were to be established, there could never be the capability to achieve the critical mass of 2,000 plus operations a year needed to maintain a research base competitive with Johns Hopkins, Boston or Texas.

With the Royal Marsden, the new Westminster and Chelsea Hospital—St. Stephen's to you and I, my Lords—and the Imperial College grouping that includes St. Mary's, we have a unique opportunity to provide a medical campus to rival any in the world, a point already raised by the noble Baroness, Lady Masham, and by my noble friend Lord McColl. What is more, an independent survey by Ernst & Young, which is to be published, I believe, later this week, will show this solution to be the more cost-effective both in patient care and in management terms. Clearly, west central London is over-provided as the Tomlinson report has indicated, but in common with my noble friend Lord Peyton, I would put it to the Government that it is the unsatisfactory, already outdated and inefficient Charing Cross Hospital that should be closed and the resources devoted to the world-class centre of excellence that exists on what I now call the Kensington and Chelsea campus.

6.40 p.m.

Lord Kilmarnock

My Lords, I start by thanking the noble Lord, Lord Annan, for giving us the opportunity to debate the Tomlinson Report. The 33rd speaker will have had all his foxes shot, so it remains only to reinforce certain points. I wish to talk mainly about primary care, but before that I have a couple of questions about hospitals.

My first question relates to genito-urinary medicine and its clinics. At present all major hospitals run such a clinic. They have been an important bastion in the control of sexually transmitted diseases, not least HIV and AIDS. Of the larger EC countries, we have been by far and away the most successful in controlling the AIDS epidemic. Confidential walk-in clinics have played a vital role in that success, not just for London residents but for its 1.3 million daily commuters. Under these plans, such clinics will almost inevitably be reduced. Have the Government given any thought to what will replace them?

My second point relates to administration and manpower. An eventual reduction of something like 25 per cent. to 30 per cent. in London's hospital doctors seems to be envisaged. It was widely reported that between 1987 and 1991 the number of managers had increased by over 1,000 per cent. across the country. Will London management bear its share of that weight-reducing regime? The noble Lord, Lord Carr of Hadley, was also worried about the administrative load. Shall we still need four Thames regional health authorities post-Tomlinson?

I turn now to primary care and the pursuit of some elusive figures. The philosophy of Tomlinson and the King's Fund Commission Report, which has been mentioned, is that the big general hospitals are the dreadnoughts of the service, and in any case there are too many of them in the Port of London. If that is accepted, many questions arise on how the transfer to lighter craft is to be made. Both Tomlinson and the King's Fund agree on the relatively poor state of primary and community health care in London, which has worse premises, more single-handed GPs, fewer practice nurses and other ancillary staff than the rest of the country. That was referred to by a number of noble Lords including the noble Lords, Lord Hayhoe, Lord Walton and Lord Young.

Writing in the British Medical Journal of 7th November, David Metcalfe, professor of general practice at Manchester, sets out his priorities for making the shift to primary care in inner cities a reality. It is worth reading. Encouragingly, he writes that there is an increasing number of highly idealistic young GPs who see the inner city as a professional challenge to be tackled head-on, but there are enormous obstacles. The primary sector is already under-resourced and overloaded. There is a high burn-out of practice nurses and staff. In some violent areas, even their physical safety is at risk. Professor Metcalfe wants not merely an improvement in premises, but a van-based service with a driver for the practice team, an expansion of community and cottage hospital beds, and the maintenance of, say, one out of every five or six practices on a 24-hour basis to cope with emergencies.

Tomlinson also wants neighbourhood nursing teams and other things such as nursing homes and day centres for the mentally ill and frail. As the list of community health requirements grows, it becomes clear that this revolution will not come cheap in the short and medium term. In paragraph 49, Tomlinson refers to a systematic transfer of resources over a period of years, but he then recommends that there should be a transitional increase of funding to build up the community health service in advance of a reduction of acute sector capacity. That is an important phrase. It is the crucial point. It was referred to by the noble Lord, Lord Carr, and the noble Lord, Lord Young. It makes sense to have one's new facilities in place before closing the old, but one will not yet have any help from closures or site sales.

Tomlinson puts no overall figure on those transitional policies, so I turned to the King's Fund Report which recommends a £250 million primary and community health care development programme for London. Some feel that that is inadequate but it depends upon what it is meant to cover.

Appendix 4 of the King's Fund Report estimates a release of £200 million a year from the acute sector, but that may not help us for several years. In the meantime, the King's Fund wants £216 million for capital costs and £164 million annual revenue costs for 90 new community-based health centres. That tots up to something over £1 billion over five years. Tomlinson has spoken only of £140 million over that period, mainly for improving existing premises. There is a big discrepancy here, and I am inclined to put more faith in the King's Fund figures.

Tomlinson is, of course, an architect's preliminary drawing only. We have yet no measured working drawings to give to the masons. Tomlinson recommends an implementation group with, I think, sector working parties to report within six months. We seriously need to see its more detailed and, one hopes, more accurately costed proposals, over which I suggest a good accountant should have crawled with a magnifying glass.

We are extremely fortunate in having the noble Baroness, Lady Cumberlege, as the health Minister in this House. She is more alive to the problems than most of us. She was, as the noble Baroness, Lady Jay, said, a member of the King's Fund Commission until the general election, when the Secretary of State for Health sensibly persuaded her to accept this appointment. Will she give us an assurance that the Government will return to Parliament with a clear statement of the stages of the plan, the timescale and the transitional finance available? It is not just a question of Parliament. This is more than a reorganisation. It is a cultural revolution, and the confidence of everyone concerned, not least the patients and the staff, as the noble Lord, Lord Hunter of Newington, said, has to be won before we embark upon this worthwhile but difficult adventure.

6.45 p.m.

Lord Pitt of Hampstead

My Lords, I too should like to thank the noble Lord, Lord Annan, for giving us the opportunity to have this debate. I must confess that when I read the Tomlinson Report and noted its aim to shift more care from the secondary to the primary sector in London, I was thrilled. There is an opportunity for imaginative innovations in general practice in London. If seized, the medical services in London can be improved dramatically. Life would be improved for the people of the many races and cultures who together form the community of London.

That, frankly, was my first reaction. Then I remembered that in London the primary sector is already under-resourced and overloaded. I realised that the essential improvements required in primary and community care in London could take place only if sufficient funds were made available. I further remembered the lasting effects on London of the extensive closures of long-stay psychiatric hospitals over the past decade, and the totally inadequate alternative provision made for the continuing care of the patients who were thus decanted into the community. At that moment, my enthusiasm waned.

I began to think and to dig more deeply. I decided to examine the waiting lists. I found that for general surgery, 44.8 per cent. of district health authorities in London had long waiting lists compared with 29.5 per cent. for England as a whole; and that for traumatic orthopaedic surgery 51.7 per cent. of district health authorities in London had long waiting lists, compared with 33.9 per cent. for England as a whole. Then again, I discovered that on 31st March 1992 there were 256,517 people on the waiting lists of the four Thames region authorities, and, that of those, 28,340 had been waiting for more than a year. Then I remembered that in August I read a report about the horrible state of the casualty department at King's College Hospital; of people lying on trolleys for hours and of people falling off the trolleys and dying. I became less willing to accept bed closures in London.

Then I thought of the problems being faced by junior doctors who have to work exceptionally long hours, with the realisation that their situation can be improved only if more consultants are appointed. Then I found it equally difficult to defend a reduction in the number of consultant posts.

I therefore join other noble Lords who have spoken in appealing to the Government to take the state of the health service on board and, while accepting the thrust of the Tomlinson Report, to make plans to remedy the known defects in its services before effecting these changes.

The improvement in the primary sector should precede any action on the closure of hospitals and the removal of beds. Other Members have made the point and I underline it because, frankly, that is the commitment we need from the Government. The sum required should be raised by borrowing and should be spent on improving the primary sector in the knowledge that part of it will be recouped by the selling of sites—but only part. In any case, an improvement in primary care service will reduce the overall costs of the health service in London.

I agree with the noble Lord, Lord Annan, about the Royal Marsden, and disagree with him about Thomas's. Thomas's is our hospital, it is the only one we now have where we once had four. Tomlinson said that the choice between the two hospitals, Guy's and Thomas's, was, in his own words, "finely balanced". I think that the balance should be tipped in favour of Thomas's in view of our needs.

I had intended to say something about Bart's because my daughter was an anaesthetist there, in charge of the intensive care unit on the day of the bomb in the Tower of London. She would have expected me to say something, but I can write to tell her that other people said so much about it that there was no need for me to say anything other than that I agree. I hope that when the Minister replies she will be able to assuage some of my fears.

6.52 p.m.

Lord Beloff

My Lords, in joining in the thanks that have been universally expressed to the noble Lord, Lord Annan, I must include a reservation. I do not thank him for what I believe was a piece of misjudgment in confining the debate to five hours. Those of us who sat through this afternoon—

Lord Annan

My Lords, I must intervene. I had no hand at all in that. I was asked by my noble convener whether I should be willing for the debate to go on beyond five hours. I said that I was willing, but it was she who held conversations with the normal channels. They took the decision; I had nothing to do with it.

Lord Beloff

My Lords, I apologise to the noble Lord, but that was not the impression we were given earlier this afternoon by the Whips. However, the reason that I regret the limitation is simply that we have all heard many interesting speeches enlightening us on aspects of these important problems. Most speakers, I felt—and I suspect other noble Lords did also—would have benefited if they had been able to flesh out their arguments rather than necessarily speaking in shorthand. That is particularly the case because we are dealing with a document, the Tomlinson Report, which is very like that. It is written as though there was a time limit or word limit. Statements are made for which adequate argument is often not adduced.

My only purpose in rising is to do what I was condemned to do as a schoolboy—namely, to field at longstop—because I wish to be longstop to two noble Lords who have already spoken. In the first place I am longstop to the noble Lord, Lord McGregor, who talked about St. Mark's Hospital. I took part in the delegation to the previous Secretary of State to whom he referred and I share the noble Lord's pleasure in the fact that the Tomlinson Report endorses the principle of moving St. Mark's to the district general hospital at Northwick Park where substantial accommodation is being made available.

Like the noble Lord, Lord McGregor, I hope that when the noble Baroness winds up she will be able to say that the sum necessary for the cost of the move into these new quarters, which I understand is in the region of £8.5 million, will be found as part of the general exercise. That would mean that one important centre of excellence, world-famed both in teaching research and patient care, would have a permanent and rosy future.

I also wish to act as longstop to my noble friend Lord Elton in regretting—I am not sure that he put it that way—the absence of any emphasis on research in the report. The word "research" appears in the title of the report, but nowhere in it is there, as one might expect, a discussion of what is necessary for a flourishing research community or the importance of such a community in London.

The noble Lord, Lord Elton, referred, rightly and advisedly, to the economic advantages which the country and London in particular derive from its worldwide fame as perhaps the major concentration of clinical research anywhere in the world. It seems to me that a report on health in London might have given a little more emphasis to that fact.

Quite apart from the economic advantages, I think noble Lords would also feel that there should be some stress on the pride which this country—which has many problems about which it grieves—can still have and would maintain in having in its capital such a major centre of clinical research. It is a balm to our spirits at times that there are spheres in which we still lead the world.

Therefore, one wonders why there is this downgrading of the research element. As noble Lords will be aware, I am always inclined to look for the dead hand of the Treasury whenever I come across something I find uncomfortable. But I suspect that research may also be suffering from the idealism of the medical profession. I pointed out to someone who was defending en bloc the Tomlinson Report that some people were worried that it might lead to the dissolution, break up or disappearance of famous teams in medical research. He said, "Oh, it doesn't matter, they can go and do the research in America or elsewhere". No doubt from a global point of view that is correct. But from the national point of view I should have thought that keeping these centres of excellence and teams engaged in pushing forward the frontiers of medical knowledge is something we ought to stick to at all costs.

6.57 p.m.

Lord Harmsworth

My Lords, I wish to join those who thanked the noble Lord, Lord Annan, for introducing the debate. There can be few who are more qualified to do so. What will particularly commend him to your Lordships in this debate is his former position as provost of the first institution to open, in the 1830s, a hospital built especially for teaching purposes—University College, London—and his later vice-chancellorship of the University of London. On the fourth day of the debate on the loyal Address, he said that he was a reformer. I very much hope that having heard your Lordships this afternoon he will be able to help us in that area.

I am unapologetic in my support for action over London's health service, medical education and research, broadly along the lines espoused by Sir Bernard Tomlinson. I wholeheartedly welcome the report and I also commend the stance taken on it at this stage by the Government. Let us think carefully and use well-established NHS consultation procedures before taking any major decisions.

A top-down prescription for London health care and education has been an imperative for many years and was needed well before the 1990 health Act. But up till now the way ahead has been less easy to discern with any detailed clarity. The 1990 health Act reforms have, as indeed they were intended to do, sharpened the focus. Distortions have been made plainer. It is now much more certain how and why rationalisation should take place. Essentially health services should follow the people. They should also adapt to the circumstances. At hospital level I would cite as a shining example St George's in its move from Hyde Park Corner to Tooting.

Over the centuries health provision has been haphazard and unco-ordinated. It was largely in the gift of monasteries in the middle ages; the sovereign on their dissolution; and the civic authorities in the middle of the 16th century; and they were funded then from a hotch-potch of sources—charities, the sovereign, rent, fees and tolls. In London for the next two centuries there were only two real hospitals: Bart's and St Thomas's. Many of the fine establishments covered by the Tomlinson Report—St George's, Guy's, London, Middlesex and Westminster hospitals —were general hospitals founded in the 18th century. That was the age of the general hospital. Those specialist hospitals mentioned may claim descent from the 19th century —the age of the specialist hospital. It is small wonder that loyalties are strong and that feelings run deep. Feelings ran deep when many fine regiments amalgamated. Who would have countenanced the idea, as National Service was ending, that my own regiment, the Royal Horse Guards, ("the Blues"), would later amalgamate with the Royals? One would have said, perish the thought! However, a happy marriage it became.

The recommendations made by Professor Tomlinson are detailed, comprehensive, far reaching, radical, complex and urgent. Some of the foundation stones on which parts of the new edifice will stand have not yet been fully fashioned. Let that be no cause for delay. Some of those on the supply side will be far from sure that the moment is right. Ideally, more time for preparation would be desirable, they say. Some will take issue over the detail of the recommendations. Some will say that the new ground is too untested for such radical change of emphasis. I have a folio of letters testifying to all of this. I also have many in support.

The report is not new either, in an historical context or in its approach and findings. Just after World War One a committee, under Viscount Cave, reported on the voluntary hospitals. Of the 672 hospitals considered, 378 were in debt. It was recommended that voluntary hospital committees should be set up covering the whole country, dividing it into 46 areas, each charged with encouraging co-operation between hospitals and investigating hospital needs for the area.

The 1929 Local Government Act gave local authorities wider powers to provide hospitals and required them to consult voluntary hospital committees on hospital provision. Again, in a 1937 report Viscount Sankey recommended a top-down regional approach to hospital provision and funding based around central hospitals. That same year Political and Economic Planning published a survey of British health services based on the work of 200 investigators. It drew attention, among other things, to the large number of agencies, competition and overlapping.

I do not envy the Minister the long hours she may spend studying critical-path charts if the Tomlinson Report recommendations are implemented, which I sincerely hope they will be. Such a sea change in London health provision and medical education and research will demand the best and most competent management skills. When I first read this report I sensed a dichotomy. On the one hand there is an urgent need to reduce inner London hospital beds capacity, the better to match supply and demand, and to rationalise education and research. On the other hand there is a need to restructure health service provision in favour of primary and community health services which are currently underdeveloped and which in London trail behind their provincial counterparts.

Let us as much as possible—I hope that the forthcoming consultations will focus on this—form a view, however tenuous, on roughly what we want to end up with, particularly in the areas of education and research. That way management of the changes will be the easier to handle. I see this largely as a handling exercise and less as a debate about basic need. One way or another, changes there will be. Let us manage those changes.

7.5 p.m.

Lord Broadbridge

My Lords, I congratulate the noble Lord, Lord Annan, on bringing forward this very timely debate. However, I am appalled at the prospect of having to deal with Tomlinson in six minutes. I shall therefore largely confine my remarks to his hospital proposals, and within that, to his proposed murder of St. Bartholomew's which is 869 years old this year. It has been in continuous operation on its present site since 1123. Bart's is, with the possible exception of a hospital in Padua, the oldest hospital in the world. One has to be pretty virile to survive that long and I hope to show that Bart's is no less virile now than in the past.

But when considering new proposals of great breadth, it is better, I believe, to move from the general to the particular before drawing up one's own personal conclusions. I am a believer that prevention in the first place is a better strategy than cure after things have become serious. In this spirit I welcome the main thrust of the report which is to recommend a greater emphasis on primary and community care. It is not with what Tomlinson is trying to do as just stated that I find a problem: it is with how he is proposing to do it that I part company with him. What he has not produced is an arguable and acceptable solution. As a business consultant, what strikes me forcibly is that, having put his proposals up for discussion, he submits no business and financial plan. How on earth can strategy be confidentially recommended without first following its implications through? Perhaps I may ask the noble Baroness who is to reply whether such is happening as part of the Government's announced policy of no decisions before full consultation.

I now come to Bart's. I must speak plainly as a local and former patient. As far as I and many respected voices are concerned, Tomlinson's assessment of Bart's is that of an intellectual dwarf. His basic statistics are wrong and his assumptions are wrong. Therefore I urge that his recommendation; namely, at paragraph 122, which is the, orderly run-down and disposal of the Smithfield site be disregarded.

First, he relies upon Bart's having an exclusive (that is, local) population to serve of 34,775. But the chief executive of Bart's, Professor Besser, told me last Friday that Bart's provides for 539,000 drawn from South Hackney, South Islington, 5,000 living in the City, mainly the Barbican, and the City's own estimate of 314,000 daily commuters and visitors. That is 15½ times the Tomlinson figure, and Tomlinson deduced from his own fallacious exclusive population figure a prime reason for Bart's being closed in that it will be unable to fill beds and therefore be non-viable in the new NHS market.

Bart's is also very importantly the almost exclusive recourse for City accident and emergency cases, handling 39,713 at Smithfield in the year to March 1992. That is over 100 a day. In accidents and emergencies, minutes are often literally vital. The 10 minute isochrones at the back of the report showing alternative suitable hospitals are disputed by Bart's and the London ambulance service.

Secondly, in paragraph 119 Bart's is said to be in severe recurrent financial difficulties; at present some £4 million. But this deficit only and shamefully results from providers not paying for Bart's services. The hospital is on course to exceed its contract provision by an astonishing 27 per cent. or 13,000 patients this year, and if money was truly following the patient, Bart's would have received £22 million extra revenue at full cost or £4.4 million at marginal cost. So much for the working of the internal market.

Thirdly, Tomlinson argues that Bart's, in comparison with other inner North-East London hospitals, ranks second highest in its level of excess costs, and it has the highest capital charges. Perhaps a major reason is that Bart's has, quite inequitably and amazingly, to incorporate the full notional rental value of its City site in its costs—a staggering impediment over its competitors. The buildings are indestructible, the main block recently requiring its first external renovation for 240 years. They are also adaptable—although Tomlinson says that there is limited scope for development and rationalisation—in that £60 million has been agreed as worthwhile spending in the past five years. That includes, as we have heard, the most advanced operating theatre in Europe.

Fourthly, Bart's is efficient. That is one of Tomlinson's main criteria for comparative hospital assessment. Income per clinical academic post is among the three highest in the UK at £135,000. One in three patients at Bart's is now treated as a day case, a recognised measure of efficiency and progressive clinical practice. That is more than double the level of its competitors.

The North-East Thames Regional Health Authority gave Tomlinson evidence on possible future improvements in efficiency but he chose not to use that evidence in his report. He recommends the closure of the hospital with the best record of efficiency. Bart's has contracts with 55 purchasing authorities. Its nearest London rival has 35. Fifthly, when ill and overcome, one has to be able to get to one's hospital. Bart's enjoys probably the best public communications network one could hope for, unlike the Royal London in Whitechapel and Mile End, to which Tomlinson recommends it be removed.

Sixthly, the professor spent three and a half days at his old hospital of UCH and five hours at Bart's. He did not visit Bart's 400-strong research establishment at Charterhouse Square and refused to go to its associated Homerton Hospital at all. Is that evidence of a balanced approach?

In conclusion, Bart's stands on its own very demonstrable merits. So far a quarter of a million people have signed a petition to save Bart's. To dissolve it would produce a tide of deep resentment at an injustice done among its half million users—and voters—which, for many of them, would sweep the Government's health plans en bloc into the mental dustbin. As I am sure the Government know, the dustbin is not a good place to be.

7.12 p.m.

Lord Lyell

My Lords, at the outset I should like to thank my noble friend the Minister, who wrote me a letter, which she topped and tailed, and sent me an excellent copy of the report inviting me to read it. So I did, and that is why I am standing here today. I should also like to thank the noble Lord, Lord Annan, for giving us the opportunity to hear what has been a marvellous debate, even though time limited. I assure my noble friend on the Front Bench that I shall not be long.

The four headings on page 1 of the report seem very clear to me. The strategic aims of what the report set out to discover were also fairly clear. It seemed that the timescale of the report was only five years in some aspects, and perhaps longer in respect of other recommendations. However, what scared me considerably was the colossal geographical area covered by the medical services discussed in the report. I had no idea of that until I looked at the report.

Perhaps I am the only one out of 38 speakers not to have a special interest in the report. In paragraph 8 of the report your Lordships will see, printed in heavy type for the short of sight like myself, a warning of serious and haphazard deterioration in the health services in London if some of the report's recommendations are not taken seriously. I do not think that the Government are likely not to take them seriously.

The acute service is referred to in the summary of recommendations in paragraph 13. Above all, the fall in the use of what are called in-patient beds is dealt with. First, there is a move to cheaper local alternatives, perhaps outwith the area covered by the report. Secondly, the continuing efficiency of the acute sector is an objective of the report. My noble friends, Lady Eccles and Lord McColl, covered that aspect.

I was somewhat startled to read in paragraph 55, relating to community health services, of a new concept—primary health care teams. The noble Baroness, Lady McFarlane, referred to those teams, as did my noble friend Lord Jenkin. I am sure that all of us are grateful to those teams for all that they do in improving the overall health care of everybody in London, not just the 2.5 million people who are said to live within the area covered by the report but also the 1.3 million daily commuters who have been referred to in relation to the St. Bartholomew's catchment area.

It was when I came to study the acute sector in detail that I became slightly scared. I think that I have managed to understand some of what was spelt out; but I am sure that my noble friend the Minister will be able to explain to me —if not tonight then perhaps in a letter or at a later stage—what is meant in paragraph 90 on page 24. In all my studies of accountancy I have not yet come across "episodes of acute care". I am sure that that means something to medical specialists dealing with the acute sector. It gradually became clearer to me as I read through the report. I did not want to put a human face on those episodes,. and I shall not do so tonight.

Also in connection with the acute sector, I looked at paragraphs 107 and 108 which deal with the current financial pressures. The one point which stood out was the considerable financial pressures on all the different specialist sectors found in the huge area covered by the report.

I should like to ask my noble friend the Minister whether there is a practical solution to the problem which was raised with me in relation to the Royal Marsden Hospital, Charing Cross Hospital and the Royal Brompton Hospital. I hope that there is. Of course my noble friend will not be able to go into detail tonight. Perhaps it may take a little longer than five years, but I hope that a solution will be found.

Paragraph 119 on page 32 deals with one other fascinating subject, which was touched on by the noble Duke, concerning a 10 minute isochrone. I believe that I am right in thinking that that is the area within which a person—perhaps an episode of acute care—could be moved to a centre of acute care within 10 minutes. I believe that everything relating to the acute sector covered that 10 minute factor.

I should like to congratulate Sir Bernard Tomlinson on the report. It made a great deal of sense to me as an accountant. I await the wise words of my noble friend, the Minister.

7.18 p.m.

Lord Rea

My Lords, because of the time factor I am afraid that I shall have to omit some of the customary courtesies. However, as we are doing rather well for time I shall, with the leave of your Lordships' House, speak for a little longer than six minutes. Nevertheless, I shall try to be brief and, luckily for your Lordships, I shall omit a funny story with which I had originally intended to begin. Also because of the time factor I shall not be able to mention certain rather important aspects of the report.

As an aside on the discussion we have had about the short time for each noble Lord to speak, I differ from the noble Lord, Lord Beloff. I believe that the discipline of having to produce one's thoughts in six minutes has been rather useful. It has made the debate rather more interesting and less dull than many I have sat through.

Yesterday evening I attended a crowded British Medical Association meeting together with some 400 other doctors. That meeting was addressed by Sir Bernard Tomlinson. After outlining his report to us, Sir Bernard answered some questions. When asked why the report contained so little statistical backing he said that everyone loved to destroy a report based on statistics. When so much is at stake I feel that that attitude, while perhaps good for a laugh at a meeting, is irresponsible. I should like to thank the noble Lord, Lord McGregor of Durris, and the noble Lord, Lord Dainton, who drew attention to the shallow academic base of the report and its poor documentation and referencing.

In a letter to the British Medical Journal on 21st November (the same issue that the noble Lord, Lord Jenkin, referred to but in a different section) Professor Brian Jarman, on whose very careful work the Department of Health has relied in the past, wrote: Bed usage by London residents if geriatric services are included (they were omitted in the Tomlinson and King's Fund analyses)"— and that is quite a revelation is no greater than the national average. In inner London usage is lower than (and bed supply about equal to) other comparable areas". That point was made by the noble Lord, Lord Annan, in his opening speech.

I raised the letter of Professor Jarman with Sir Bernard, who said that it did not really alter his main recommendation to reduce bed numbers in inner London by closure of some whole hospitals. I must say that I disagreed with him, and disagreed with him quite fundamentally.

At present, London's hospitals are under acute pressure. My noble friend Lord Pitt mentioned how long the waiting lists are. It is my opinion, and the opinion of nearly all other GPs to whom I have spoken in London, that it is more difficult to admit patients to London hospitals than it has been for some years. It is true that one reason for this, as Sir Bernard pointed out in his report, is that some of the inner London beds are used by outer London residents. There is indeed an excessive concentration of highly specialised units in inner London, leaving less room for run-of-the-mill acute services. Even if these problems are addressed and all those matters are taken into account, using Professor Jarman's figures, there will still not be any great surplus of beds.

London's hospitals are, and will continue to be, more expensive than other hospitals. Some of the extra cost is possibly avoidable. For instance, there is a very high staffing ratio in teaching and specialised units. That could possibly be brought down through rationalisation of the specialised services between hospitals, moving some units elsewhere, as Sir Bernard suggests, to outer London where those services do not exist. St. Mark's, of course, is one.

Other costs which accrue in London are at present unavoidable—not capitation weighting but, for instance, salary weighting in London whereby people are paid a little bit extra, and the capital charges that were imposed on hospitals after the last National Health Service Act. Here I definitely follow the noble Lord, Lord Broadbridge: this is a rod that the Government have made for their own back. In my opinion, inner London hospitals should be compensated for their unavoidable additional costs. A figure of between £50 million and £100 million—I believe the noble Lord, Lord Annan, mentioned £70 million—is the extra cost of keeping the London teaching hospitals going. Some people might say that that is rather a reasonable bargain, considering the very high standard of work that those hospitals do. I think it is true that some high-cost beds could be converted to low dependency, low-cost use. As many noble Lords have mentioned, general practitioners could be involved in running those beds, as they could be and are being involved in accident and emergency services. In fact, 70 per cent. of the work in many accident and emergency services is general practice. But closure of whole hospitals and selling off sites is, in my view, entirely the wrong approach if a good service, locally accessible to Londoners, is the aim.

This Government, as we all know, are a poor guardian of the nation's assets. In this case, following the analogy drawn by the first Lord Stockton of the rather nice furniture in the sitting room, we are talking perhaps of the servants' quarters and perhaps (because of the fall in property values) even the west wing of the stately home. Rather surprisingly, Sir Bernard does not recommend selling off the folly in the garden, which I think is not a very unkind description of the UCH cruciform building.

The expansion and modernisation of primary care in London, as suggested by Sir Bernard and almost every noble Lord who has spoken, is long overdue. I greatly welcome, and these Benches as a whole greatly welcome, this section of his report, whatever happens to London's hospitals. But to expect even the best units in primary care, run with a full team of nurses and other health professionals, quickly to bring London's hospital bed usage down to a lower than national level is however quite unrealistic.

Good premises are, of course, a basic need in good primary care. The only cost mentioned in Sir Bernard's report is £140 million over several years relating to premises alone. In the King's Fund Report £250 million was mentioned, as the noble Baroness knows well. But it is much easier and cheaper to construct a building than an effective primary care team. The skills to man the secondary care centres mentioned by the noble Lord, Lord Hunter, and others would take many years to develop—at least five years, and more likely 10 or 20 years.

When asked why he had not costed his recommendations, Sir Bernard said at the meeting last night that he did not have the time and that it would be very speculative to do costings. That is partly true.

Baroness Trumpington

My Lords, I wonder whether the noble Lord would sit down. I am in the hands of the House. I realise that extra time has become available but in such a long debate perhaps your Lordships might like to give the Minister more time to answer all the questions. I hope the noble Lord will forgive me if I ask him to give way to the Minister.

Lord Rea

My Lords, let me make some concluding remarks. Perhaps I may draw the noble Baroness's attention to Sir Bernard's own words in paragraph 30, summarising much of what other noble Lords have said: Recognising, however, that hospital expenditure is not flexible in the short term, we believe that in the early stages, this re-direction of resources"— from hospital to community— can only be achieved by providing new money in order to facilitate change". Can we please have from the noble Baroness her commitment to the fact that this new money will be available and can we see a demonstration of this before any beds are closed down?

7.30 p.m.

Baroness Cumberlege

My Lords, I am grateful, to the noble Lord, Lord Annan, for initiating today's debate. As a distinguished former Vice-Chancellor of London University he is well-versed in the issues surrounding education and research; and as a former trustee of the British Museum he will not only have a sense of history but a knowledge of the burden of ancient monuments.

I share the view of my noble friend Lord Lyell that this has been a splendid debate and of great value to the Government. I welcome too the contributions of the three illustrious "maidens". My noble friend Lord Braine of Wheatley, although a new arrival in your Lordships' House, is a much-respected Father of another House. His experience in representing the constituents of Castle Point for 42 years will have made him aware of the capacity of London to draw in resources to the detriment of other local services. The noble Lord, Lord Spens, brings a wealth of knowledge to this Chamber from the City and from other areas. I hope that his personal and intimate experience of the National Health Service will diminish from now on. Perhaps I should confess to my noble friend Lord Hayhoe that, unlike Mrs. Patrick Campbell, I have, alas, no experience of a chaise longue but at the age of 17 sank blissfully into a matrimonial bed, sadly without a substantial dowry.

That anecdote is not entirely disconnected with today's debate since, as the noble Lord, Lord Annan, pointed out, much of the Tomlinson strategy centres on arranged marriages to which some parties are consenting but others are the most reluctant of brides, as is their right. Rarely can a subject for debate have attracted so distinguished a list of speakers, and the causes of concern been made so plain. It is therefore with relief that I can give a categorical assurance that the Government have an open mind on many of the issues raised tonight and will take them into consideration when they respond to the Tomlinson proposals in the New Year.

Before I come to answer the individual views expressed by your Lordships I should, first, like to place on record the Government's gratitude to Sir Bernard Tomlinson and his team. I understand some of the reservations expressed by your Lordships, including the noble Lord, Lord Rea, who made his first appearance at the Dispatch Box, which I welcome.

However, I am disappointed by some commentators who have sought not to debate the report but to cloud the issues by discrediting the report and the detail of its findings and recommendations. In doing so they ignore its major and inescapable conclusion; that the status quo is no longer an option for London. This urgent need for change was also the main finding of the report published by the independent King's Fund Commission in June which was based on a wealth of research. The Government are determined to face squarely the issue of rejecting the status quo. If London's problems are not addressed the prospect of a spiral of decline for the capital's health services—about which Sir Bernard warns—is very real.

The Government welcome the general thrust of Sir Bernard's report and are now listening to all the views expressed before making our response early in the New Year to the detailed proposals. We have already announced the Government's acceptance of the main recommendations to improve medical teaching and research. Moreover, we have accepted the need for a series of specialty reviews which we shall initiate as quickly as possible. Those reviews will address the question raised by the noble Lord, Lord Hunter, and the powerful point made by the noble Baroness, Lady Masham of Ilton. This is because we accept the need to consolidate and thereby strengthen specialty provision in the capital. Only by doing so can we ensure that London will continue to have world class centres of excellence in the next century.

We are setting up a special implementation group, already mentioned tonight, under the chairmanship of Mr. Tim Chessels to carry forward a programme of change. The noble Lords, Lord Walton and Lord Dainton, will be pleased to learn that a member of the Universities Funding Council will be a member of that group. Although no decisions regarding hospital closures or mergers have yet been taken, nor will they be without using the well-established NHS consultation procedures, the Government have sought to ensure that there will be a means of implementing London's new strategy when it has been agreed.

My noble friend Lord Carr and the noble Lord, Lord Kilmarnock, can rest assured that the group is not another tier of administration but a speedy and accurate tool for change. Nor is it a decision-making body. It is for the Government to decide. The group will implement.

I cannot agree with the noble Lord, Lord Desai, and the noble Baroness, Lady Jeger, that this is not an urgent issue. However, I agree with the noble Lord, Lord Hunter, my noble friends Lord Carr, Lord Hacking, Lady Seccombe, Lord McColl and Lord Harmsworth, who believe that it is urgent.

Over a period of decades London's health services have become increasingly out of step with the needs of Londoners. As my noble friend Lord Hayhoe so eloquently pointed out, the large expensive teaching hospitals, most of which were built before the decline in London's population, have swallowed up the lion's share of resources while health services delivered by GPs, community nurses and others in the community and primary care areas have remained poorly developed.

Several speakers today have spoken eloquently in defence of London's teaching hospitals. Although the Government value tradition and recognise the respect and affection which those great institutions generate, they also recognise that it is simply not sufficient to rest on past glories. London's institutions must adapt to change if we are to achieve the improvements in London's health services which are widely agreed to be necessary.

We were privileged today to hear the president of Bart's the noble Duke, the Duke of Gloucester. My noble friend Lord Braine of Wheatley and the noble Lords, Lord Molloy, Lord McGregor, Lord Spens, the noble Baroness, Lady McFarlane, and the noble Lord, Lord Broadbridge, cogently put the case for St. Bartholomew's Hospital. But the position of Bart's is no different from any other institution covered in the Tomlinson Report. As with the rest of London the Government seek the solution which will safeguard the health and health care interests of London and Londoners.

Whatever the solution there are a number of key issues that have to be addressed. Bart's is running a very large deficit; a minimum of £5 million this year. Financial management in the hospital leaves a lot to be desired. Bart's has the smallest exclusive population of any London hospital. It is very vulnerable to patient withdrawal. Between 30 and 40 per cent. of its patients come from outside its own or immediately neighbouring districts. Bart's is expensive; it has the second highest level of excess costs in London, making it even more vulnerable to patient withdrawal. The Government are fully aware of the symbolic importance of St. Bartholomew's Hospital to London and the affection in which it is held nationally. It has made an enormous contribution to the development of medical science in the United Kingdom. Some units—for instance, the oncology, endocrinology and surgical units—are world renowned. However, the Government are charged with developing a strategy for London well into the next century. In shaping it we must look to Londoners' future needs.

The noble Lord, Lord Richardson, spoke with great authority on the strength of St. Thomas's Hospital, as did the noble Lord, Lord Pitt. I have great sympathy with their view which will be taken into account when the Government reach their conclusions on the detail of the report. As regards the move of St. Mark's Hospital, I can assure my noble friend Lord Beloff and the noble Lord, Lord McGregor of Durris, that we are aware of the capital costs and we are seeking to resolve that issue.

I accept that for many people, particularly Londoners, it is hard to see how reducing hospital beds will improve services. However, there is a London paradox. More money is spent on the health care of Londoners than on people living in any other part of the country. Yet Londoners have to wait longer than others for some operations and there are persistent problems with emergency admissions to hospitals in inner London. People in outer London have to travel long distances for specialist care.

Against that background, proposals to reduce beds make little sense to most people. However, many of those problems of access stem from the concentration of specialty provision in inner London. The Tomlinson Report documents 14 regional cardiac specialty services; 13 specialty centres for cancer; 13 for neurosciences; 11 renal units; and 9 units for plastic surgery. All are in the centre of the city.

In addition, the pattern of care in inner London is skewed with a higher proportion of elective work to emergencies. Given that, it is clear that we need to look not just at absolute numbers of beds but, sparing Mrs. Campbell's blushes, at what goes on in those beds. Londoners, particularly those with common conditions and frail elderly people who were mentioned by many noble Lords, have not been well served by this concentration on specialty services and on elective work. Mergers and confederation of specialist units are needed to counteract wasteful fragmentation and safeguard excellence. As that is done, the Government are confident that a better pattern of care for Londoners can emerge as well.

As my noble friend Lady Eccles of Moulton pointed out, there is a revolution occurring in medical practice. Many more conditions are treated as day cases. Other conditions can be treated at home or in the GP surgery. Throughout the NHS there is a steady trend towards greater efficiency in the use of hospital resources: length of stay and turnover interval are shortening everywhere. Sir Bernard Tomlinson has found that inner London hospitals are significantly less efficient in their area of resources than those elsewhere, even after allowing for the effects of their care-mix and teaching commitments. That too suggests that a consolidation of services can take place without adverse effects on Londoners, as London's use of resources improves.

As my noble friends Lady Eccles and Lord Harmsworth suggested, that excellence is not just to be found in London. The greatest achievement which has happened in my lifetime has been the establishment of centres of excellence throughout the length and breadth of the UK. People in the South West no longer look to London as they did in 1948. They go to Bristol and to Exeter—a point that was made better by my noble friend Lord McColl. The NHS reforms are now enabling health authorities outside London to seek more local, and more cost-effective care for their residents. All that is leading to a sharp drop in demand for hospital beds at London's teaching hospitals.

Those changes are already having a powerful impact. Several hospitals are facing serious financial problems as they can no longer match their costs to their contract income. The University College/Middlesex Hospital, for example, is facing a deficit this year of some £13 million. Other hospitals are in a similar position. I must make it clear that these problems are not due to under funding. Sir Bernard Tomlinson has documented the fact that, when all due allowance is made for the excess costs of operating in the capital, London's costs remain some 20 per cent. above the national average. That is compelling purchasers to seek better value for money elsewhere.

I turn now to primary care or perhaps I should take my cue from a former Secretary of State, my noble friend Lord Jenkin of Roding and add the word "community". I am grateful to the noble Lords, Lord Winstanley and Lord Young of Dartington, for pointing out startling facts about the level of primary care and the challenges of working in inner London.

London has some quite outstanding and innovative general practitioners: Professor Bryan Jarman (already mentioned in the debate this evening), Dr. Patrick Patroni, my noble friend Lord Rea who has practised with John Horder, one of the founders of the Royal College of General Practitioners, to name but a few. But those beacons of excellence stand out in a service that is below that commonly found in other parts of the country. We recognise, of course, the difficult circumstances in which many GPs and community nurses carry out their work: the inadequate premises, the high costs of living, the traffic congestion, the need for protection when making home visits and the challenging health and social needs, which are so evident in some parts of London. But many GPs offer very limited services to their patients. As the noble Lord, Lord Winstanley, pointed out, access is poor. As for many Londoners the first point of call is the accident and emergency department of their local hospital. Clearly, that must change.

The noble Baroness, Lady Jay, highlighted the very real issues as regards primary care. I am sure that the noble Baroness and others will welcome Sir Bernard's imaginative package of measures for improving family health services in the capital, including employment of GPs in accident and emergency departments. I assure the House, and in particular the noble Lord, Lord Hunter, and the noble Baroness, Lady McFarlane, that we are giving Sir Bernard's proposals and other models of primary care very serious consideration.

The noble Lord, Lord Annan, my noble friends Lord Joseph and Lord Hayhoe, the noble Baroness, Lady Jay, and the noble Lords, Lord Pitt, Lord Kilmarnock, Lord Smith, and Lord Young of Dartington, and my noble friend Lady Cox were all anxious about resources and asked where the money is to come from. In the long term, it will come from a better organised, cost-effective and more efficient use of acute services. However, I am afraid that the noble Lord, Lord Cocks of Hartcliffe, must exercise his good humour and patience before we reveal the total figure.

In the short term, the Government recognise that they will have to lubricate the wheels of change. My right honourable friend the Secretary of State, always a doughty fighter for the NHS, secured an extra £1 billion for next year. The Government will use some of that money to begin to build the new structures necessary for primary care and for a new configuration of acute services in London. She will announce those figures in the new year. Change will not take place overnight. It will be incremental. We shall need to ensure that there is a steady injection of funds over a period of years.

I should like to address briefly the discrepancy raised between the King's Fund and Tomlinson figures as regards primary care. There are two issues: first, the timescale, because both reports were working to very different timescales; and, secondly, the type of services envisaged, because again the two bodies had a different profile of future primary and community care in London.

I can give the noble Lord, Lord Kilmarnock, the assurances that he seeks as to timetabling and the other issues he raised.

As the noble Lord, Lord Walton of Detchant, a recent president of the General Medical Council, pointed out, the basis of medical teaching is changing. In the past, too much attention has been concentrated on London's 11 teaching hospitals, incredibly all within a six-mile radius. Other hospitals outside central London provide good services giving better value, and can be used for teaching medical students. London University is already making use of these hospitals. But more needs to be done so that teaching follows the patient into general hospitals and increasingly into primary and community care. With one-third of all medical students being trained in London, it will prove difficult, if not impossible, to ensure that they get the necessary experience in general practice during their course of study.

I agree with the noble Lord, Lord Dainton, that linking medical schools to university colleges with strong departments of life sciences should strengthen both teaching and research. Integrated medical schools will be better able to provide the range of subjects required for medical students in future. At present, the costs of clinical teaching in London are some 15 per cent. higher than the national average. But the schools which are already part of multi-disciplinary colleges have below-average costs, so there are both academic and financial benefits to integrating medical schools in the university.

The noble Earl, Lord Russell, and my noble friend Lord Elton quite rightly pointed to the economic benefits of research. My noble friend asked how the Treasury will be involved. In my very short experience of government I have yet to find a sacrosanct area in which the Treasury is not involved.

The great progress currently being made in medical research, for example in genetics, is science-based not clinically-based. To achieve high-quality clinical research the bond between universities and medical schools must be strong. That is reinforced by the evidence of the quality of research. London attracts half of all clinical research income, and the average research income per academic is around one-third higher than the national average. However, the Universities Funding Council, which assesses the quality of research, has rated only University College of the nine general medical schools in London as being above average, whereas six non-London schools were above average. It is commonsense to build on the most successful pattern of organisation and to judge on results actually achieved.

The thrust of the changes suggested by Sir Bernard is to strengthen both teaching and research in London. It is a fact that the noble Lord, Lord Flowers, was pressing for many of these changes as far back as 1980 in his excellent report. I am glad that his successor, the present Vice-Chancellor, has welcomed many of the changes in the report.

The Brompton and the Royal Marsden special hospitals were particularly lauded tonight by my noble friends Lord Hacking, Lord Peyton of Yeovil, Lord Stockton, the noble Baroness Lady Masham of Ilton and my noble friend Lord Lyell. The Government recognise that many of the London postgraduate institutes are highly rated both by the patients and the UFC. But that rating depends on the facilities provided by the special health authority hospitals which are currently not part of the NHS market.

We are determined to maintain and reinforce the best research. But much of the NHS work in the special health authority hospitals meets specific patient needs and can be funded through the NHS market with support for the extra service costs of research. I can assure my noble friend Lord Elton that the Government will exercise the greatest care in ensuring that the new arrangements reinforce the best research in those centres while allowing high quality institutions outside London to benefit from NHS support for research. As my noble friend Lord McColl pointed out, the present rules are discriminatory and unfair.

Several noble Lords referred to the need for the detailed research implications of the Tomlinson Report to be re-examined. To enable the Government to come to the right decision for the special health authorities we have started a comprehensive review of their research. The special health authorities have been asked to provide evidence to Professor Peckham, the director of research and development, and it will be examined by international and national experts.

In conclusion, London is Europe's largest city and the capital of this country. In the next century it will be vital for it to provide its citizens with world class specialist health services and top flight primary care. To safeguard excellence and build quality services the Government are convinced that a major programme of change must be devised and implemented for the capital, in consultation with the professions, health and local authorities, provider organisations and other interested parties—most notably Londoners themselves.

That is a most formidable challenge. But to fail to confront it would be to invite the "spiral of decline" which the Tomlinson Report so eloquently describes. London deserves better—much better. That is why the Government will be announcing their response to Sir Bernard's recommendations in the New Year. We are confident that our plans will permit new and better health services to develop in London—ones that will build on the excellence of the past while meeting the changing needs and expectations of tomorrow's patients.

7.52 p.m.

Lord Annan

My Lords, it remains for me to thank the noble Baroness for summing up in such a splendid and full fashion and to thank everybody who took part in the debate for exercising enormous restraint upon their own eloquence. Time has obviously been a tiresome and telling problem for them.

Naturally, I particularly want to thank the maiden speakers who gave such admirable speeches today —the noble Lord, Lord Hayhoe, for his courageous logic; the noble Lord, Lord Braine, for the sincerity and forcefulness with which he expressed his dissent; and the noble Lord, Lord Spens, for an uncompromising conclusion. One remark he made I particularly liked, which was that he, like myself, experienced some difficulty with the acronyms in the report.

The report is about the future. That is something that is difficult to predict. Many of the conclusions in the report are based on what best informed opinion thinks is likely to be the pattern at the end of the century. I am sorry that I nettled the noble Lord, Lord McColl. I hope he knows that I have always greatly admired what he has done to put his shoulder behind the wheel of change and reform. If he felt that there was any kind of personal criticism meant, he is quite mistaken.

When he asked why, when I was Vice-Chancellor of the University of London, I was unable to obtain reforms, I can only answer that while I obtained agreement among the deans of the medical schools —a feat of no mean ability—the Senate of the university, which was composed of 50 to 60 people, few of whom were doctors, threw out the recommendations of the report. That is what happens in political life. Therefore may I conclude by begging leave to withdraw my Motion for Papers.

Motion for Papers, by leave, withdrawn.