HL Deb 13 December 1993 vol 550 cc1220-60

10.1 p.m.

Baroness Jay of Paddington rose to ask Her Majesty's Government what proposals they have for hospital services in London following the Tomlinson Report and the reviews of medical specialties which they established earlier this year.

The noble Baroness said: My Lords, I beg leave to ask the Question standing in my name on the Order Paper. I do so because it is over a year since the report by Sir Bernard Tomlinson on London's health care service and medical education. It is 10 months since the Government made their proposals in Making London Better and six months since the review of medical specialties in the capital. At the same time, London's NHS is facing the imminent threat to its financial resources through the introduction of weighted capitation funding in the next financial year—capitation funding which, it has been estimated, may mean cuts of £100 million over the next five years.

Although throughout 1993 the Government have been promising a speedy resolution of all those problems in which all the pieces of the complex London jigsaw will be firmly welded together, so far there has been a resounding silence. No strategic plan has appeared; and at present London's health care is suffering a particularly destructive form of planning blight.

Nearly everyone who has looked at London's health services agrees with Sir Bernard Tomlinson's general conclusion that some rationalisation and reorganisation should occur. Equally, everyone agrees that there must be proper extensive consultation and, above all, that changes must not just mean cuts.

I am certainly not asking for rapid decisions, which simply lead to hospital closures; particularly if there is no adequate primary care to replace hospital out-patient clinics and accident, emergency and casualty departments, which today many Londoners use because GP services in the capital are so inadequate.

My Question is simply a plea for an end to uncertainty. It is not an invitation to axe wielding. Since the Question was tabled I have been inundated by approaches from those who use the NHS in London and those who work in it. Their general message is that something must be announced soon. I hope that tonight the Minister will be able to respond.

Many of the most heartfelt comments have come from health service managers; those who are charged with making the new internal market work. I quote one chief executive who, perhaps with rather typical British understatement, wrote: We are making dramatic and difficult changes—we have reduced bed numbers by almost 20 per cent. We have reduced our prices for next year by 12 per cent. To maintain that rate of progress and maintain, any degree of confidence among the staff—in an environment which combines threat with ambiguity—is not the easiest thing I have ever done". At the same time, the Greater London Association of Community Health Councils, representing users' interests, has produced its own assessment of the current situation. The one I have here is called not Making London Better but Making London Worse. It shows that some hospital waiting lists have lengthened by 19 per cent. in the past year, while this hiatus has been going on and that accident and emergency departments are being substantially cut back. The CHCs say: Changes are happening in a haphazard chaotic way". They, too, call for decisive planning.

I recognise that it is philosophically difficult for the Government to abandon the concept of the market and to adopt "decisive planning" to intervene to manage London's health care, but if they do not there will be chaos.

I shall resist the temptation to re-open the general argument about the overall validity of the market approach to the NHS, although I suspect some of my noble friends will not do so. However, I remind the Minister that there were those gloomy soothsayers who predicted that the internal market would collapse in year three, precisely because of the kind of problems thrown up by the types of configurations of providers and purchasers that we see in London and, indeed, in other large cities. They are configurations which really cannot be reconciled without a strategic plan. For example, there is little point in a specialty review recommending that cardiac surgery should be removed from hospital A and expanded at hospital B if the purchasers, the local providers of funds, continue to prefer hospital A and finance contracts accordingly. We have seen many examples all round London of that kind of problem arising.

However, I hope that in the future all this may be academic because some of the nods and winks and some of the unofficial briefing that has come out of the Department of Health suggest that Ministers are going to intervene. They are going to dilute the pure milk of the market and take responsibility for managed change. The Secretary of State for Health, in her February statement on Making London Better, spoke of grasping the nettle. We have recently seen special central funding for special health authorities to ease their way into a new system and new funds for some primary care development.

There are also indications that the headlong dash to allow market forces to change everything all at once may be slowing down. I hope that is true and that if the Government are prepared to take time to direct and manage they will take time to consider again three particular issues of London' s health services.

The first question is the old one of whether or not there is over-provision of hospital beds in London. This always seems like Alice in Wonderland to those who use London services, those who are on the lengthening waiting lists or being treated in beds in hospital corridors. Nonetheless, the statistical consensus has been that London should lose about 2,500 beds. But since both the King's Fund Commission and Tomlinson said that in 1992, Professor Brian Jarman and other community health experts have done some additional work on the realities of medical and social care for Londoners. They point out the need for hospital beds to cope with the inner city's ageing, deprived population which is not being supported by scarce community care. Figures have also been produced to show that although London has 12 per cent. of the population, it has only 9.6 per cent. of psycho-geriatric beds and only 4.2 per cent. of the country's voluntary and private nursing home beds.

Of course, in an ideal post-Tomlinson world, those gaps would be filled. However, not surprisingly there is a certain cynicism about new money for appropriate community care and a wish to hang on to acute beds while there is nothing else available. The example of what has happened with the reorganisation of mental health care is the awful spectre which many people consider. It really seems to be an exact illustration of the Belloc dictum that you should, Always keep a-hold of Nurse, For fear of finding something worse".

I hope that tonight the noble Baroness will tell us whether or not the Government are really still convinced that there is over-bedding, in the jargon, in London.

The second major question is about the so-called "centres of excellence". That has become an unfashionable phrase but it is one that describes the special London medical institutions which have world status in both teaching and research. I recognise, as I said earlier, that the Government have given special transitional help to special health authorities—the SHAs. But that does not meet the concerns about the potentially fatal disruption of research and the break-up of specialist teams which could well occur if, for example, local purchasing priorities are exclusively allowed to determine the reorganisation of the Hammersmith and Charing Cross Hospitals in West London, with the Postgraduate Medical School at the Hammersmith being threatened with closure. Nor does special funding for SMAs meet the problem of hospitals like UCH and the Middlesex, which do not fall into the favoured category but have the highest national ratings for undergraduate teaching and research. Their first class work is now threatened by the purchasers in the market, as my noble friend Lord Ashley of Stoke showed in his Question to the Minister last week.

Those centres of excellence have made the National Health Service what it is. They have given national leadership to national care, national teaching and national research. They have meant that the National Health Service is not just a safety net for the poor but a real world leader in the development of medicine. It is crazy to try to downgrade their work. After all, if we are to look at the NHS as a business—I hope that we do not have to do that exclusively—any good business would put huge resources into research and development. To try to abandon that, simply in order to pursue the ideology of the market at the local level, is purely destructive. I ask the Minister tonight: does every hospital have to be an all-purpose district general hospital, or can managed change encompass both district general hospitals with all their marvellous services to local communities and the centres of excellence which provide the outstanding contribution to national health care?

Thirdly, there is the question of special resources to facilitate change. In a recent letter to The Times the chief executive of the King's Fund echoed many others by saying that there must be clear guidelines for next year which crucially include money to fund capital expenditure. He said that there was all the difference in the world between telling people to merge and giving them the means to do it.

Your Lordships will have seen last month's proposals by the Joint Trust Board of St. Thomas's and Guy's, which wants to co-ordinate their services but to retain both sites because: The capital funds to achieve a single site are unlikely to be made available … at this time". Similarly, the plans geographically to concentrate Bart's, London and the London Chest Hospital on the London's Whitechapel site are meeting financial scepticism even from those who support the merger in principle. There is mounting concern that if a merger is pushed through without adequate investment there will be a piecemeal division of specialties between the sites, which could well lead to a reduction of overall services rather than consolidation and expansion. Therefore I hope that, even if the Minister is unable to give details of the Government's plans, she will be able to reassure your Lordships that overall, adequate capital investment will be made to facilitate change when it does occur.

There may well be a case for managing change in London steadily but slowly—perhaps, for example, using one part of London as an area of action research to see how well services will settle down; or first making strategic decisions about siting accident and emergency departments and then building the pattern of specialty services and acute bed provision on the basis of those. As I said earlier, my Question is certainly not designed to provoke macho management, let alone an immediate scorched earth policy towards London hospitals. It is to try to get the Government to break their vow of silence on what they intend.

Fourteen months ago Sir Bernard Tomlinson forecast a "spiral of decline" if action were not taken. Ten months ago the Secretary of State said: We have accepted the need for radical change. We will deliver it". I hope that tonight the Minister will tell us how and when delivery will happen.

10.15 p.m.

Baroness Robson of Kiddington

My Lords, when I saw that the noble Baroness, Lady Jay of Paddington, had tabled this Question on the Order Paper for today, I hoped that it would not come up at quarter past 10; above all I hoped that we would have had more of an indication from the Secretary of State in regard to what she is planning to do. It was mooted in the press that an announcement would be made before the Christmas Recess. I sincerely hope that that will happen and that an indication will be given this evening regarding what the future holds.

I agree 100 per cent. with the noble Baroness, Lady Jay, that the most devastating effect to the health service is the feeling of not knowing where it is going at the moment. As she stated, it was in February 1992 that Tomlinson reported. I remember clearly the Government's response shortly afterwards when the Secretary of State was expected to make an announcement in early February 1993. She did; she set up the London Specialty Review, which was a step in the right direction. But that did not quiet the worries of people in the various large London hospitals.

At that time the implementation committee was appointed. No doubt it is necessary; we need an implementation committee. but I should have thought that we would need some guidance on how to implement before we needed an implementation committee.

There is no doubt that the rationalisation of services is based on the assumption by the Government that there will be financial savings, presumably of revenue. But, above all, what worries me is that there does not seem to be any estimate of capital expenditure to implement rationalisation. There is limited knowledge and that knowledge is highly underestimated. For instance, the Royal Marsden and the Royal Brompton hospitals commissioned Ernst & Young to provide costings for closure and relocation to Charing Cross—at one time that was a suggestion. It was found that Ernst & Young estimated costs of £76 million as compared to Tomlinson's figure of £15 million. That is a huge discrepancy. Having been married to a chartered accountant I believe that the chartered accountants are more likely to be correct.

Another example is that of the problems of the Royal London and Bart's, and the new consultative document which was circulating, and to which one had to respond by 10th December, in regard to the amalgamation and creation of one trust for the two hospitals. Can the Minister say how much money has been wasted over the past year in creating the Royal London Trust, which will now need to be dismantled and amalgamated with Bart's? There is a great danger that money was wasted on that exercise. As the noble Baroness, Lady Jay, asked: what will it cost to relocate the departments in Bart's at another site?

We all know about University College Hospital and Middlesex. Those two hospitals managed to work well together. But almost every month one hears a different answer to what the solution may be. That is not helpful. It has been said that the same thing applies to St. Thomas's and Guy's.

We cannot decide to close established institutions; we cannot assume that their facilities and expertise are transferable like pieces on a chessboard. Centres of excellence, at the forefront of their fields, which have built up a body of skills, research, loyalty and repute cannot simply be broken up, redeployed and recreated at regional or district level elsewhere. The value attached to tradition, length of service and the corporate ethos may be difficult to quantify but its dismissal would be unwise. That is what concerns me very deeply about the latest proposal that the Royal Postgraduate Medical School may be moving to Charing Cross, abandoning Hammersmith where it has lived very happily and very successfully for many years.

Then there are other hospitals which feel vaguely safe—they know that they will survive as such—like the Royal Free. However, their services are nevertheless to be broken up. The suggestions for the Royal Free, for instance, are that all the transplant services should go, that the dialysis should stay and the children's dialysis should go. It is good that the dialysis is staying because that has to be within reach of patients. But equally, every patient who has a transplant is required to attend at the hospital for a long, long time afterwards to be checked and monitored. A move would mean patients having to travel a long way. Most of the patients at the Royal Free come from north of the location of the hospital.

What disturbs me most of all about the Royal Free is the danger of breaking up its paediatric department, which is one I admire very much. Most of the paediatrics except for accident and emergency are to go to Great Ormond Street. If accident and emergency remains there it means that the patient will have to be transferred after his initial admission. That jeopardises the very excellent special care baby unit in that hospital.

One could go on repeating examples of the fragmentation of services that we all require. What worries me is that in many cases this will mean patients having to travel long distances. That is not easy in London. It is so easy to say that it is only two or three miles from here to there but to travel two or three miles in London is a lengthy exercise and does not always land you up at exactly the place where you want to be. There is not always a convenient Underground station and there is hardly ever anywhere to park a car.

That is quite apart from all the disruption that has happened to the morale of staff in the hospitals. I know that the Secretary of State gave certain assurances that senior staff, medical professionals and nurses would all be helped to relocate. I have said before that it is not only the top grades in the hospitals that we have to think about. It is all the staff in the hospital. To relocate is not all that easy. People have a life apart from their job. They have a home. They have children who go to a certain school. It is not necessarily possible to accept an alternative appointment somewhere quite different.

I should also like to ask the Minister whether she is perfectly happy about the fact that we have in place, or we are within reach of having in place, the right community services to undertake this enormous exercise of streamlining all the London hospitals and all the specialist hospitals. I do not believe that we have. And, until we have, we do not have the right to deprive Londoners of their services, which are mainly based in the hospitals and not in the community.

I would like to finish with a word of thanks to the Minister and to the Secretary of State for having solved the problem of one hospital. We are all delighted that St. Mark's Hospital will move to Northwick Park in Harrow; that this has been agreed on both sides and that everybody is happy.

10.25 p.m.

Lord Carr of Hadley

My Lords, this is one of those occasions when I would have preferred to speak after the Minister rather than before her. I should know much better what I wanted to say if I knew first what she was going to say. However, such is life. I must also admit that when I put my name down last Thursday to speak in the debate I expected it to be on a much narrower front. I was motivated by the reports of the great fears that the decision which the Secretary of State announced as regards the Royal Marsden Hospital last February was in grave danger of being reversed. I confess that that was my motivation in wanting to speak in the debate. I shall attempt to broaden my remarks although I shall use the Royal Marsden as an example of the points want to make.

From the beginning of the proposed reforms of the health service by this Conservative Government some three or four years ago I have consistently and strongly supported the principles of those reforms. I am wholly unrepentant about that. As each year goes by I become more convinced that they were right in principle. I have criticised them pretty heavily at times on detail, but I have always strongly given my support in principle. I feel sure that the basic principles now being operated will persist and will never be repealed and changed fundamentally no matter what government come to power.

The changes are leading to a much better health service although of course there are serious teething troubles in the transformation of a huge organisation like the National Health Service. After all, it is the biggest employer in this country, if not in Europe. My approval of principle extends to the way in which the Government have tackled the London problem which has been hanging over us for a hundred years. The Government have had the guts to tackle it head on and to provide the Tomlinson Report. Having got that report and following a due but certainly not over-long period of consideration, the Secretary of State made her Statement which my noble friend repeated in this House last February.

I was among most Members of your Lordships' House in believing that the way in which the Secretary of State dealt with the report was admirable. She had come down to a number of what seemed to me firm, basic decisions of principle while reserving a number of more doubtful points for further consideration. My concern now is that it appears that some of those decisions of principle are being threatened. It seems to me that my right honourable friend the Secretary of State and my noble friend the Minister have saddled themselves—perhaps I should say, have been saddled—with a very strange system of decision-taking. It may not be strange to those on the inside, but it is extremely strange to those on the outside. It is not that the matter takes time, because decisions of this kind should take time. Although the issues are extremely urgent they are also very deep and important and basic decisions should not be rushed.

I understand that the Tomlinson Report included the proposal that specialty groups should look at different specialties in the different hospitals. I understand that that was a process which had to go on. I understand fully that that is not a policy-making but more a fact-finding and fact-recommending exercise, which the Secretary of State has to take into account. What has surprised me—indeed, I would say shocked and almost angered me—is that these specialty groups seem to have charged into their subjects as if no decisions of principle had previously been taken by the Secretary of State. Had they come along, looked at all these matters and said as regards the Royal Marsden Hospital, "The Secretary of State has decided that that hospital should stay. What is our recommendation given that fact?" Instead, they have plunged into the matter not only as regards the Royal Marsden, but also other hospitals, as though the Secretary of State had given no thought at all and had made no decisions at all. I find that tiresome. I am sure that patients, doctors, nurses and administrative staff, as well as interested members of the public, are equally exasperated. I understand why there is pressure on the Government to make a final announcement as quickly as possible, and I certainly want them to do so. However, I do not want them to do so without mature consideration. Therefore, although the matter is urgent, haste may not be a good thing. I say to the Secretary of State, "Please take as little or as much time as you need to form your final decisions and then announce them to us".

My plea tonight is that the Secretary of State should stick to the basic decisions she announced, so far as she was able to, in Parliament last February. I cannot remember whether we in this House actually had a debate or merely questions on a Statement. Those were wise decisions which set people's minds at rest. To a certain extent, people knew in which direction they were heading. They knew that some things were still to be decided, but they believed that certain basic decisions had been made—and firmly made. All the reports which have now been given or leaked to the press—I do not know which—seem to call all that into question. That is immensely disturbing and worrying, not only to staff, but also to patients.

My main purpose tonight is to make a plea to the Government to stick by the decisions they made—in so far as they made them—and which they announced last February. Then, as quickly as possible, they should produce their final decisions in full detail.

Perhaps I may say a little more about the Royal Marsden. It seems to me that we in London face a problem. For many years there has been an over-provision of resources in London in relation to the rest of the country and relative to need. In addition, needs are changing because the quality of general hospitals and other facilities outside central London has improved. Therefore, some reductions have to be made, and they are bound to be painful. The Government have faced up to that and are going that way. However, it is still extremely important that we keep within London centres of excellence—centres of excellence for treatment in particular specialties, centres of excellence in research and development and centres of excellence which patients can visit easily.

When I look at the complex of the Brompton Hospital, the Royal Marsden, the new Chelsea and Westminster Hospital and Imperial College Medical School, it seems to me that tucked into a fairly neat geographical area we have a university city in medical terms, and that to start sending parts of those facilities out to general hospitals in Chelsea and elsewhere is madness. It is a waste of resources to break down a centre of excellence which is of great benefit to patients and which has a great reputation throughout the world. That is not the way to reform.

Specialty groups have now come along, looking at the subject narrowly and with blinkers on. They cannot look to the right or the left but only straight down the ends of their noses. That tends to produce a short-sighted result. I say strongly to the Government, in the interests of staff, doctors, nurses, scientists, students and patients, "Please stick to the basic decisions announced last February and do not allow yourselves to be diverted by the special pleading of people who, I believe, have a very blinkered outlook on the needs of the country."

10.33 p.m.

Baroness Masham of Ilton

My Lords, I thank the noble Baroness, Lady Jay of Paddington, for giving your Lordships the opportunity this evening of asking the Minister some questions about the life and death situation of people living in and coming into London who need health-care. I speak from these Benches with no political axe to grind, but I want to speak from a patient's point of view and to say that, whatever the Government's intentions were when they instigated the Tomlinson report, they have managed to cause patients anguish beyond any person's comprehension.

Maybe the Government realise how insecure hospital workers feel over the upheaval caused by the report and the reviews. All I can say is that it is minimal compared to what is felt by ill and dying patients whose lifeline is a specialist hospital unit. What has this country come to when patients suffering from cancer or renal failure who are fighting for their lives are having to expose themselves to try to save the hospital, or hospital unit, which they know and trust and which is their only hope of survival?

No one would argue that we do not need efficiency and cost-effectiveness in the NHS, but the market culture seems to have a hardening effect on the staff's attitude towards patients. Can the Minister, for whom I have the highest regard, put her hand on her heart and say that the report Making London Better has made it, or is making it, better? The emphasis is on cost-effectiveness. The most cost-effective procedure is to let ill patients die. That is what is so worrying when one has a hard and uncaring society. I hope that the debate will do something to alert the Government, who have a mania for closing down so many things, to a realisation that ill people need good management at their bedside as well as at board level.

Beds are needed for patients, and senior staff are needed to support patients and junior staff on the wards. I witnessed, at first hand in a London hospital, a sister on an acute ward on which patients were undergoing serious operations who never went onto the ward. When patients queried why they never saw the sister they were told by junior nurses that she was interested only in management, not in patients. Hospitals are increasingly using temporary staff—known as "bank" nurses—to cut costs. Lack of continuity of care is bad for patients, especially children. Managers who do not know the nurses create a dangerous situation, for many different reasons. One is that nurses sometimes do two jobs to make more money, and fall asleep on their feet.

Two weeks ago I visited a desperately ill patient at one of London's teaching hospitals. The patient and his parents told me that by far the best nurse came from the bank. She had the highest qualities, an abundance of TLC and several qualifications. The hospital would not take her on the permanent staff because it was cheaper to keep her coming from the bank.

Last Friday, I saw my GP in Yorkshire. He had just returned from an international conference in Edinburgh, where Bart's Hospital was discussed. The Americans present said that, if the British Government closed down Bart's, it would be like closing the Mayo Clinic in the US. Hospitals such as Bart's and the Mayo Clinic are valued throughout the world. Does a good reputation mean nothing to this Government? I heard also last week that Britain is short of doctors. The medical and nursing schools of St. Bartholomew's Hospital are world famous. No wonder we are short of doctors: we have already amalgamated several medical schools. Are we going to shut down more? Is it true that we may have to import doctors?

Why are we getting ourselves into this unnecessary and dangerous situation? A cousin of mine who graduated as a junior doctor last year from Bart's is now working in Plymouth. Young doctors do not all stay in London. They move all over the place. Neither the Government, nor Professor Tomlinson in his report, seem to take that factor into consideration. It is easy to close down a good hospital with the stroke of a pen, but it takes years to build up experts who trust one another and work together.

London is a popular place. Hordes of tourists come to visit and many people come to work here. They become ill and take up acute beds. Has Tomlinson taken that into account? Tonight's London Evening Standard states that London hospitals are full. What are the Government going to do when they close more beds?

The break-up of the medical teams causes disharmony and fear among patients. It destroys teaching and research, and in the long run the operation is expensive in so many ways. In order to conquer some of the difficult problems now facing us, which seem to be insurmountable, does the Minister agree that there needs to be a concentration of good brains, good morale and good co-operation, with decent research facilities?

What do the Government intend to do about the drug-resistant tuberculosis present in the East End of London among the homeless and refugee population? That is not just a health matter; it is to do with bad housing and poverty. But as shown in America, the disease is very dangerous to people who have HIV and AIDS. Why should that type of TB be spreading among women? I mention that because it is a new development since the Tomlinson Report. Furthermore, why has Britain such a bad record of breast and ovarian cancer? It is generally recognised that all forms of cancer should be treated in cancer specialist centres. The Tomlinson Report, the review of medical specialties and the Government's wish to close the world-famous Royal Marsden Hospital has thrown into dismay and disbelief the people with cancer, the people who have been treated and have recovered, the loyal supporters who have done so much to raise money for this frightening disease and the expert staff.

Both the Secretary of State and the Minister responsible for health issues in your Lordships' House are women. Women feel that more should be done—instead of sending the morale of specially trained staff and cancer patients spiralling down to rock bottom. What could be worse? It is not only Londoners who are worried about health services. The ripples of hope of new drugs and research have spread from the Royal Marsden Hospital throughout the country.

One of the six specialty reviews is that of children's services. Many families face financial hardship as a result of visiting their children in hospital. A survey carried out by Action for Sick Children, called "Too Dear to Visit", showed that nearly 6 per cent. of families go into debt as a result of visiting and 26 per cent. said that they would like to visit more. The importance of parents visiting their children every day is recognised by professionals, the Government and everyone else involved in the health and welfare of children.

Families who are suffering emotional strain as a result of a child being in hospital are suffering financially too. The campaigners have met the Minister for Health, John Bowis, who said that the Government would keep the position under review. With Christmas so near, I hope that the Minister will be able to give more hope today. Sick children in hospital should not feel isolated and rejected by their families. Children do not understand poverty and debt and the expense of travel. They just need their parents.

Many people are anxious about the ever-increasing management costs in both primary and secondary medical care. Whole new departments have been established for the marketing of services. I ask the Minister whether her department is monitoring those extra costs and balancing them against direct patient care services.

Last week I sent the Minister a letter from a young man from Wandsworth who telephoned to tell me that he had been in agony because of a rod in his back due to scoliosis. He went to his GP to ask whether he could have an opinion from scoliosis experts at the special unit at Stanmore Orthopaedic Hospital. The GP told him that because of lack of funds that was not possible. He says that he cannot tolerate the pain so he has been given pain killers. That is not a very satisfactory situation for a young man in his twenties.

In The Times on 9th December there was an article headed: More consultants to be appointed. Minister pledges to improve patient care". How can he do that if doctors are telling patients that there is not enough money to send them to the expert units which can help them? What Ministers and GPs or purchasing authorities are saying does not seem to add up. It is no wonder that patients are confused.

Every time we have a debate on the health of the nation, the Minister says that the health service is treating more patients than ever before. I am sure that that is true, but until the admission figures are broken down each year to new admissions and re-admissions, it is difficult to see a true picture. It may be that a person is admitted several times because of complications. Would that not be useful information to have?

Re-organisation always seems to be very expensive, but is it better? With the contracting culture has come a hard line of treating patients as numbers rather than as human beings. Patients respond to a personalised approach.

With the increasing violence in London through drug-related crime and the use of the gun and the knife, the population of London feels increasingly vulnerable each time an accident and emergency department closes down. We live in a very difficult society but it would be made easier if the needs of communities and individuals were dealt with in a more sensitive and understanding way.

On Friday of last week I was telephoned by a member of the press who is making a film about patients who have died from pressure sores. How can people whose friends and relations have died from such preventable conditions accept that millions of pounds should he spent on managers' cars? It seems to be the patients who are coming off worst. It is tragic that health authorities cannot afford to provide the health care needed by their populations because they have spent so much money on litigation claims.

I asked the Minister a supplementary question on 2nd December about the burns unit at Queen Mary's Hospital, Roehampton. She replied that there are 14 such units which serve London. That may be true for plastics, but the burns unit at Queen Mary's Hospital is the only such specialty with a London postal address. If the Department of Health gets the answer wrong to such a simple question, how can we be sure that the Tomlinson Report and reviews are not also wrong in some of their recommendations?

10.49 p.m.

Lord Bruce of Donington

My Lords, the House will have listened with the deepest sympathy and appreciation to the speech that has just been made by the noble Baroness, Lady Masham. I say to her and to the House that it has been an honour to be here and listen to her, because she has gone back to basics.

The general attitude of the noble Lord, Lord Carr, is, "For God's sake say something, if only goodbye". That is his attitude towards the Minister. But then, of course, I am familiar with that attitude. I am sorry to have to go back a little into the past, but when the noble Baroness, Lady Cumberlege, was five years old, I was in this Chamber helping to pilot the National Health Service Bill through the House of Commons (which was sitting here at that time). Moreover, the Secretary of State for Health, Mrs. Bottomley, had not yet been born. I shall forgive her for that because it was an event beyond her control.

However, this much I do know and I shall recount it to the House quite truthfully—and, indeed, it can be gathered from the records which are still available here; they are not subject to the 30-year rule or anything of that kind. When the Health Service Bill was introduced, I well remember that it was met with the unremitting opposition of the Conservative Party in the other place (sitting opposite to where I am standing now). I remember that, day after day and night after night, they fought it line by line and clause by clause both in Committee and on Report. They even went to the extraordinary step of voting against it on Third Reading.

Of course, the Bill struck right at the roots of Conservative philosophy that the free market—that is, market and commercial forces—should determine everything. The reason why the Secretary of State is in some difficulty today in arriving at the decisions that she is supposed to take is precisely because she has learnt as a matter of practical experience since the publication of the Tomlinson Report, to which I shall refer presently, that the idea of planning the resources of a health service while having it run on commercial and profit-making lines, subject to market forces or the alleged consumer choice of the customer (the patient) does not work; they simply do not mix. You cannot run a service which depends on the vocational dedication of people whether as doctors, nurses, specialists, ancillary workers, or whatever they may be, as a service to humanity within our country and reconcile that with the necessity to subject it to what are called "internal market forces".

The Secretary of State has now found that out, although it is a bit late. Of course, it may well be in conformity with current government practice that she prefers to leave the announcement of any changes that she makes until the Recess. That is the customary device employed by Conservative Governments in recent years: they either put a stooge Question down for Written Answer in the other place or they make the announcement during the Recess when there can be no parliamentary row and when there is always the possibility that additional publicity directed towards the domestic troubles of the Royal Family will drive what they decide off the front pages of the newspapers. We are well familiar with that technique. However, I hope that that is not the case. I hope that the Secretary of State is in genuine anguish as to the decision that she proposes to take.

I do not propose to become involved in the merits of the opening or the closure of individual hospitals because that is exactly what the Government want. They want everyone to be involved in an internal row, preferring the opening or closure of one or another favourite hospital. In any event, I am not falling into that trap. I am against the whole thing in principle and for a very good reason. The Secretary of State originally commissioned Sir Bernard Tomlinson to draw up a report and the terms of reference were quite correctly set out in Sir Bernard's ultimate report.

Sir Bernard is a distinguished member of the medical profession and the noble Baroness herself has considerable experience, going back over a number of years, in hospital administration. I would not therefore accuse her of acting in anything other than good faith. But as a professional I have examined the report by Sir Bernard Tomlinson. It is a curious document. I repeat that Sir Bernard is an eminent member of his own profession and widely respected as such and I would not wish to detract from that. However, he does not have the remotest clue about writing a report or carrying out an investigation leading up to the rendition of a report. I speak as one whose profession has for many years involved the writing of reports and the carrying out of investigations that are necessary for the production of such reports.

I should have expected Sir Bernard to set out his terms of reference. I should have expected him to go to the Secretary of State to correct any points of detail about which there might have been some misunderstanding. I should then expect his report to state the steps that he or his team had taken in their investigation. We do not know, for example, how many hospitals he visited. I believe he visited three, perhaps four. People may or may not consider that an adequate number, but in point of fact the report does not state how many hospitals were visited. It does not state the authentic source data from which his initial factual analysis was derived.

I should have expected, for example, as the health service involves individuals (they are called customers now) patients, doctors and nurses, that there would be some analysis of the journeys made from patients' addresses into the various hospitals. Such data can easily be obtained from computer records if it is required, allied with data on patients' ages, illness profiles, and other such data. I should have expected that data to be collected as regards those in the hospitals. I should have expected such a factual, objective approach as regards what individuals were doing whether as patients, members of the medical profession, or nurses, engaged in particular hospitals.

Then I should have expected an evaluation of the data that had been obtained. Data are never all one way: there are pros and there are cons. I should have expected the arguments to be deployed in this report for or against a particular course of action. However, there is nothing of the kind. I should have expected the advantages to be set out in considerable detail so that the whole thing could have been checked.

Finally, I should have expected balanced conclusions with cross-references to the evidence. This is an amateur's report drawn up by a distinguished professional physician but who is not capable of drawing up an objective report at all and who has operated purely on assumptions which he already shared with the Secretary of State as to the way in which the health service should be run. It is what we call in the profession a hatchet report.

It is no wonder that when the Secretary of State considered the report and its implications, he issued the document Making London Better. Incidentally, all these reports have glossy covers and are produced on glossy paper. They are produced at considerable expense so that people cannot afford to acquire them or even read them. They propose a series of steps to be taken.

Then came the difficulties. We know what happened. I know from personal experience, because I have been to the accident and emergency departments of many London hospitals. Therefore, I know what I am talking about. I have listened to patients. The BMA is quite right to say that there is already a two-tier service. I challenge the noble Baroness to deny it. She knows perfectly well that fund-holding doctors get preference for their patients.

The noble Baroness may not know, but I can tell her because I have listened to conversations, that if your doctor (whether or not you are on the NHS) contacts a hospital asking for a particular service the first question asked is whether it is private treatment or on the health service. If you happen to be insured, the second question they ask is what is the credit card number.

That is the way the service is being run at the moment. It is being run half-heartedly, and to the misery of its staff because of the uncertainties. It is also being run to the misery of the patients, who are indebted not to the system but to the people with whom they come in contact. The patients' regard for the nursing staff and doctors is undiminished, because there is a bond of personal conduct, kindness and professionalism. They hold in the utmost contempt the people revealed in the two reports from the other place relating to the West Midlands Regional Health Authority and the Wessex Health Authority. There were grossly inflated salaries. Waste and even fraud occurred among the ever-growing band of administrators, all of whom have various titles—function finders, I imagine, ancillary assessors, or whatever it may be. They are all involved with the internal market, passing bits of paper, because one department has to buy a service from another and assessments have to be made as to costs and the various additional overheads before the service is even provided. This parade of paper drowns the paperwork of the old National Health Service.

As the noble Baroness knows, in spite of all that one or two matters which have occurred since the publication of the Tomlinson Report have been overlooked. Readers of The Times for 11th December will have seen the report of the Mental Health Act Commission. I do not know whether that was taken into account in the Tomlinson Report. I can find no specific mention of it. The commission concluded that: there was an urgent need to change the allocation of NHS resources to give more to health authorities in deprived areas where the pressure on mental health services is the greatest". That Mental Health Act Commission report devoted special attention to the inner cities, not only in London but also to Birmingham and elsewhere.

This morning there was mention on BBC radio of a new menace which was not even mentioned in the Tomlinson Report: intense pollution in the inner cities. Those are matters which have arisen since the Tomlinson Report.

Therefore, in technical terms the Tomlinson Report is a worthless document. I do not wonder that the Secretary of State is hesitating over it. She may hesitate; she may not hesitate. It matters not. The lie that the National Health Service is safe in the hands of the party opposite will be dispelled, and sooner or later it will redound against the Government and they will he hounded from office.

11.5 p.m.

The Earl of Limerick

My Lords, the noble Lord, Lord Bruce, always speaks entertainingly and provocatively. But he will not be surprised if I do not follow him down that road.

It is good that we discuss this important topic this evening and perhaps elicit from my noble friend on the Front Bench responses which may allay some anxieties. For that opportunity we should rightly thank the noble Baroness, Lady Jay.

The worlds of institutional health, research and funding are dangerous areas for the layman to roam. But I am moved to do so today on two grounds. First, I have a general anxiety about the soundness of methodology and process of inquiry underlying reports upon which decisions crucial to the future of London's health care will be based—in short, the quality of the data. Secondly, moving to the particular, I am apprehensive about the future, or even the lack of a continuing cohesive future, for a specific hospital with which I have had recent association.

I have had a scientific background but I am not a medical man. The interest which I declare is as treasurer of the Cancer Appeal which in recent months raised £25 million for the Royal Marsden Hospital. During that time I naturally became very personally involved. I came greatly to admire the specialist skills concentrated at Fulham Road and at Sutton. Inevitably I shall draw my argument by reference to the situation which I have come to know, but the points to be made have a much more general validity.

First, on the quality of the information, Tomlinson's proposal to close the Royal Marsden Hospital and the Royal Brompton Hospital buildings and to relocate to the Charing Cross Hospital was based on a statement by the North-West Thames Regional Health Authority that the consequent saving would be £10.6 million. Disbelieving that figure, the two hospitals sought a costed study from Ernst & Young which showed that, far from saving £10 million, the extra costs involved, depending on some variable assumptions, would be between £47 million and £62 million. In consequence, we were not alone in suspecting that the problem of the Charing Cross Hospital—a poor building in an unfavourable location—lay behind the proposal.

Be that as it may, having started the blight, that particular Tomlinson proposal was not followed by the Secretary of State. However, hard on its heels came the specialty reviews which in good part resurrected the Tomlinson proposals.

One might therefore ask: what has changed? Certainly not the costs, my Lords. What has changed is the line of argument. As a scientist I was taught that one assembles facts and seeks to draw from them logical conclusions. To start with a conclusion and then seek facts to support it is not good science. Yet the Tomlinson review and the specialty reviews seem to start from the conclusion—it is not substantiated by the evidence—that, Single specialty hospitals are on the whole less than ideal for patient care and for research and teaching". Let us note the construction of that sentence. It is therefore assumed from the outset that each and every one—patient care, research and teaching—is better served on a non-specialty basis. Can that thesis be sustained?

In my view the thesis cannot be sustained on the evidence of the specialty review on cancer. It is a flawed approach, which, equally badly, has been shown to base its conclusions on wrong or misleading information. The principle of peer review is a sound and well tested one. That peer review, however, was not good.

The composition of the expert advisory group which was leading the peer review contained in the event few members with a knowledge of cancer, and even then only in limited fields. None, it seemed, of the review group had experience in managing research and development in a large organisation and at least three of the review group would be seen as direct competitors for research funds with the Marsden Hospital and the Institute for Cancer Research.

Then the method employed: it seems that certainly one of the review team has complained that there was no standardised questionnaire, there was no practice of the same group of people visiting each of the hospitals reviewed. Therefore, one asks, how can useful comparisons be made or sound comparisons reached?

Result: a report so full of inaccuracies and dubious conclusions that legal action is contemplated. Demands for its withdrawal, I am led to understand, received the rather strange response that it has never officially been published, so it cannot be withdrawn. Whether or not it has been officially published, it is easy enough to get hold of a copy. I mentioned it to my wife and she produced a copy for me within about 60 seconds. That specialty review required pages of detailed response to the points it made. This is not the occasion for detail: suffice it to say that the rebuttal ran to no fewer than 13 pages.

Therefore, I would have to say that I share the exasperation expressed by my noble friend Lord Carr with the approach of the expert advisory groups. I say this in sadness because, like him, I support the thinking underlying Tomlinson. I make it clear that I am not merely arguing for the status quo, I am not relying on the doctrine, "If it ain't broke, don't fix it". What concerns me is that, because the approach starts with the disputed conclusion, it is, in the area of cancer at least, swimming against an important international tide.

Maybe outsiders can see us more clearly than we see ourselves. The International Union Against Cancer picks out the Royal Marsden Hospital, together with the Sloan-Kettering in New York and the Gustave-Roussy institute in France, as the chosen model for other countries to follow, citing success—and note this particularly—in all the areas of patient care, research and teaching for basing that model.

In forming that judgment, what does the international union see? It sees world class teaching: 90 per cent. of the UK medics and nurses and a large number from overseas are trained by the Royal Marsden. It sees a critical mass of patients providing a spectrum of disease from the common to the rarest, often in the form of tertiary referral. It sees the synergy of co-location with the Institute of Cancer Research, both in the Fulham Road and at Sutton, over 100 cross-appointments, shared accommodation, a single research and development strategy, joint departments, joint prospects. It sees the synergy from the proximity of other institutions, from Imperial College, the Chelsea and Westminster Hospital and the Royal Brompton Hospital, each producing new interfaces. It sees the potential for discovery from clinical research, when parallel specialists are readily able to call in colleagues with whom they are already familiar, with developments in treatment, as it is said, from the bench to the bedside. In short, the informed observer must see what we have come to call excellence.

Excellence is won by sweat as well as by brilliance. It is won only by assembling individuals or teams with complementary skills, and it is won inch by laborious inch. It is earned of set purpose but imperceptibly over a long period. But that same excellence can be dissipated almost overnight by the disruption of established working patterns and the dissipation of unique skills.

Such a culture of excellence needs a broad balance between doctors, academics, researchers mainly at postgraduate level, nurses, carers, statisticians and whoever - teams which harmonise because they encourage and inspire one another. Break the links and where go the tertiary referrals? Break the links and what inspires the original research? Who trains the expert doctors and nurses?

The Marsden sees its own best future clearly to be on those lines, as a centre of excellence, and has presented its case accordingly. That case seemingly has been brushed aside by the specialty review.

What drives such reviews? Is it dogma? There is at least a large measure of that in evidence. Or is it cost? Here the signals become considerably confused. The Institute for Cancer Research was found by the UFC survey in 1992 to have 89 per cent. of its research categorised as being of international stature, with the remaining 11 per cent. being of national excellence. That placed the ICR 16th out of 175 assessed institutions and placed it in the top eight medical schools and institutes in the country. If dogma decrees that research of such excellence should be divorced from its integral partnership with the Marsden, why then was the Marsden recently directed by the Secretary of State to apply for trust status from April next year, spanning the period when decisions will be given - or at least may be given - on the specialty review?

I have seen the submission. I have it with me. It is impressive and forecasts small operating surpluses through the year 1996–97. Are minds already closed on that application? I believe that that would be a disgrace.

That brings us to cost. There is a case stated that two-site hospitals are inefficient. The trust proposal does not support that view. Furthermore, Fulham Road and Sutton are 12 miles apart. Working between the two has been shown to be feasible. If Fulham Road were closed and Sutton put into the St. George's trust, as proposed, it is conceded that use of the operating theatres in Tooting would be necessary. Tooting is seven miles from Sutton. Is that so very different? It is argued that good financial management would lead to treating more patients for the same money.

There is a further point which is important but not often mentioned. Many top cancer specialists have one leg in private practice in or near Harley Street. A Sutton-Tooting axis sits less easily with that than Sutton with Fulham Road.

As to cost, so far as I am aware a cost driven argument cannot be sustained. Ernst & Young in its second report estimated a cost of £21 million for the proposed relocation plans. On the other hand, the total provision of West London cancer services as set out in the trust application would cost only £1 million.

Doctors and nurses are opposed to the specialty review proposals. Managers and administrators are opposed to it. Above all, 900,000 patients and supporters who signed a petition to Downing Street are opposed to it. So what is there left to say?

I believe that there is one thing more. Most hospitals depend in part on voluntary financial support. Before its recent appeal, the Marsden could expect in the region of £2 million per annum from voluntary donations. I know what enormous effort went into raising that £25 million over the past three years for purposes which were precisely defined. The flagship of that appeal was the new block in Fulham Road, with its specialist theatres and equipment. It opened in October, just over a year ago—a few weeks before Tomlinson, as it transpired—at a total cost of £17.5 million. We have to ask whether we were flying in the face of government policy, or even warned of any risk of change. We were not. Should we therefore be punished for some indiscretion? Hardly so. Half the cost of that block, almost £9 million, was provided by the Department of Health to match money which we raised ourselves.

How do we explain to the people who gave that money that their money may be wasted? I am left with one conclusion: if closure takes place in those circumstances, with no comprehensible justification or countervailing advantage to be demonstrated, there will be no such future appeals without cast-iron guarantees of the status quo for long enough to valorise the projects which they are announced to support and to fund.

11.21 p.m.

Baroness Dean of Thornton-le-Fylde

My Lords, at the beginning of my contribution I should declare an interest. I am a non-executive director of University College Hospital's shadow trust. Although I declare that interest, it is not my intention to say why University College Hospital should be given any kind of preferential treatment. I agree totally with my noble friend Lord Bruce of Donington. We should be looking not at the parochial but at the overall provision of good health care for people in London.

However, being a member of that shadow board, I have witnessed at first hand the bewilderment and confusion and the feeling of insecurity, instability and low morale that emerged as a result of lack of decisions in regard to Tomlinson, the specialty review, and the other statements that were made. I too congratulate the noble Baroness, Lady Masham, who so clearly articulated what many people—consumers of the health service, as we are now supposed to called them—are saying and feeling.

One wonders whether the lack of strategy that is making people feel so insecure arises partly from some hope that the problem areas will wither on the vine before decisions are finally taken. I hope that that is not the case. I want to believe that the changes in the health service were motivated, in at least one dimension, by improvements for patients.

There have been leaks in the newspapers this week. I agree with the noble Lord, Lord Carr, that it would have been preferable if the Minister had made a statement at the beginning of tonight's discussion. But that is not the way of things. It is crucial that a statement be made soon—not, as one would say in business, of the salami-type variety with a piece-by-piece revealing of the policy which may be evolving. We need a strategy for London. I say that as a non-Londoner. I am from the provinces; I look in awe sometimes at the areas of excellence that exist and wonder why Londoners feel so defensive about their health service. I said that I would not make a special plea for UCH, and I do not. But on any independent assessment it has the best medical college in the country. It trains doctors for various hospitals in the provinces.

Some hospitals are being tempted to say, "Please save us because we are better than them". That should not be what the debate is about. It should be about an overall strategy for the people of London, for the people who visit London and need health care and for the people who come to London for health care which may not be available elsewhere. It is not good enough to say that the intention is to decentralise some of these areas of excellence. One cannot simply pick up a plant which has taken years of nurturing, through commitment and through experience, until it grows into a capital facility and acquires an international dimension and say, "We will now put it outside." It takes years to build up that international accreditation.

I would like to be proved wrong in my view that withering on the vine may be one of the lines of approach. I certainly hope that it is not. I should like to share with noble Lords a situation which has arisen. It is one from which I hope the Government will learn. The Tomlinson Report said in October last year that there was no reason why University College Hospital should not remain. As late as September this year the Secretary of State said that she saw no reason why UCH should not remain as a national and international centre of excellence so long as it could get its budget into line. It had a major deficit problem. It has done that. It took the view that it could not sit there and do nothing as its deficit would increase. So one of the main buildings was closed. There was the pain of staff reductions and redundancies, bed reductions and everything that accompanies that. The hospital was then faced with an announcement, not from the Government but from the Camden and Islington Health Authority, which I have to accept had a serious budget problem of reduced funding over the following three years. There was a consultative document which, if carried through, would have meant the possible closure of University College Hospital. It had nothing to do with the Government; it was the local policy which was put forward.

The authority said that it would not send any routine work to University College Hospital. One cannot do that and at the same time say that there is no reason why the hospital should not remain. We know that a hospital is an interdependent unit. The accident and emergency unit relies on the routine back-up. The routine back-up relies on the specialist provision. The first-class training of doctors in University College itself relies on its links with University College Hospital. The Government imply one thing in their independent Tomlinson Report and then, because of the situation locally, even that perceived policy is knocked sideways.

When the Government eventually make their statement I should like answers to the following questions. Without those answers any policy for London will fall flat on its face. What will be provided for the implementation of any changes? What are the Government's intentions, whatever Ministers may decide in their announcement, to ensure that the purchasers also follow that strategy and do not go off at a tangent on a different strategy because of their financial problems? The back-up for that is essential. What funding will be available for the changes that are necessary?

Tomlinson was not just about health service provision. It was also about education and research related to health care. I know that the Government have indicated that within the next three years they will bring forward a national formula for the funding of education in the medical field. Three years is a long time in anyone's book, and in medical education it is a lifetime. In the meantime the facilities which are available could falter and wither, as I said earlier.

Will the announcement, which we hope will be made before the Christmas Recess and not during it, state what arrangements are to be made for the transition between now and the national formula for the funding of education in the medical field? What will be the provisions for that?

11.30 p.m.

Lord Sharp of Grimsdyke

My Lords, those of us—and there are at least 1 million citizens—who feel passionately about the future of the Royal Marsden, welcome this debate initiated by the noble Baroness, Lady Jay. It is also timely in view of the impending decision on the future of London hospitals and medical services by the Secretary of State. In my experience it is much more productive to influence a Secretary of State before she comes to her decision than to assail her afterwards, although we shall not shrink from that task either in this House, outside in the country, or through the courts, if that, regrettably, proves necessary.

As my noble friends Lord Carr and Lord Limerick have illustrated, there are a number of Peers who feel strongly on the imperative need to retain the Royal Marsden as a centre of excellence. My noble friend Lord Peyton of Yeovil, who, because of family health reasons, cannot be present for tonight's debate, has asked me to say that he wishes to identify himself with my remarks. We each have our own personal reasons for that commitment to the Royal Marsden and I shall declare my own a little later. While it is our heart that makes us determined to prevent a scandalous destruction of a unique medical asset specialising in that dread disease of cancer, it is our head that we use to reveal the mistakes, incompetence, distortion of facts and sheer prejudice of the so-called "evidence" provided by the advisers to the Secretary of State. These are harsh words, but I propose to justify them.

Let me say at the outset that none of us is against the proposition that a review is timely on the distribution and allocation of resources to meet London's medical needs and services. London should not be immune from such critical cost-benefit analysis any more than all aspects of resource allocation, whether in the public or private sector, should not from time to time be reviewed. It is, however, not necessary, in justification of such a review, for Ministers to trot out the provocative assertion that London is consuming 15 per cent. of medical resources with 10 per cent. of the population.

Even Tomlinson recognised the unique position of London as a capital city and its concentration of research centres, medical schools and teaching hospitals—a service for the whole country. London is an international centre for tourism, with 8 million tourists in a year and a vast commuter population of 1½ million who have also to be taken into account. In any event, who is subsidising whom? As a trenchant editorial in the Evening Standard of 28th October pointed out: Is it not true that Londoners pay almost £1,800 more in taxes to the Treasury than they get back in grants and subsidies? Is it not also true that families outside the capital receive an average subsidy of £3,730 from the Government? Is it not true that Londoners pay, on average, £730 more in taxes and National Insurance than someone working in the provinces? Does not, in fact, London subsidise the rest of the nation to the tune of £8.2 billion? Is not, in short, London the milch cow from which the rest of the nation and the National Health Service greedily feeds? So let us hear no more about London getting more than its fair share of National Health Service resources.

I now turn to the quality of the advice that the Secretary of State has received on the basis of which fundamental and permanent decisions will be made, including the possible closure of the Royal Marsden. I name two main sources of tainted advice: first, the North-West Thames Regional Health Authority and, in particular, its chairman, and, secondly, the Specialty Review Group on Cancer. The campaign to close the Royal Marsden stems from the disastrous decision by the North-West Thames Regional Health Authority to build the Chelsea and Westminster Hospital, a decision which was severely criticised by the National Audit Office and which resulted in a massive overrun of £100 million. The Public Accounts Committee was even harsher in its criticism of that authority. It stated: In view of the very high costs of building in London and the generally recognised view at the time that surplus beds were increasing in the capital, we are surprised that the Management Executive in deciding to build this hospital, did not have regard to the wider pattern of hospital facilities in London and the relevant areas of the Home Counties". The consequence of this disastrous decision was that the gross misuse of scarce resources on that hospital resulted in the cancellation or delay of 24 other major schemes in the region. The ripple effect of that gross management now reaches the Charing Cross Hospital just down the road. As a result of that entirely unnecessary new hospital, Charing Cross Hospital has surplus capacity. So the chairman of the North-West Thames Regional Health Authority and his colleagues in seeking to cover up or minimise the damage of their decision seizes the opportunity afforded by Tomlinson to propose the closure of the Royal Marsden and fill up the Charing Cross Hospital. To justify this, inaccurate estimates were submitted to Tomlinson on the costs of such transfer. The previous scandalous underestimate of the costs of building the Chelsea and Westminster Hospital has now been matched by the deliberate gross underestimate of the costs of closure of the Royal Marsden, as pointed out by the noble Baroness, Lady Robson.

Within the past few weeks it has been reported that the Chelsea and Westminster Hospital is heading for a £1 million deficit and has a surplus of 112 empty beds. What a bureaucratic disaster! And this is the health authority which has the temerity to advise Tomlinson, the Specialty Review Group on Cancer and the Secretary of State on how to rationalise the cancer needs and services in London by recommending the closure of the magnificent centre of excellence of the Royal Marsden. It seems to me that the only way for this regional authority to avoid further public scrutiny and censure for its incompetence is to be rescued by the Secretary of State in her welcome decision to abolish all regional health authorities as presently constituted.

I now turn to the second tainted source of advice—the Specialty Review Group on Cancer set up to advise the Minister on service, teaching and research in cancer in London. The composition of this group has not commended itself to leaders in this specialist field of oncology. Be that as it may, as the chairman of the group was assisted by the chief executive of a purchasing agency in North-West Thames Regional Health Authority it is not very surprising that the group resurrected the Tomlinson proposal to close the Royal Marsden and transfer cancer services and research to the Charing Cross Hospital. This despite the fact that the Department for Education in assessing the research quality of the nation's academic institutions graded the Royal Marsden as sixth in the country and the Charing Cross Hospital as low as 53rd.

The report of the Specialty Review Group on Cancer has been justly condemned as tendentious, misleading and full of inaccuracies and deliberate mis-information. It is like something out of Alice in Wonderland, "First the sentence and then the verdict".

It is now clear that the North-West Thames Regional Health Authority in its desire to cover up its fundamentally flawed decision to build the Chelsea and Westminster has exploited the assertion made by Sir Bernard Tomlinson that, single specialty hospitals are on the whole less than ideal for patient care, and for research and teaching". That is an assertion made by one man—sincere no doubt, but challenged by his peers not only in the country but throughout the world. I say "assertion" because no evidence is adduced in the Tomlinson Report.

Sir David Weatherall, the distinguished professor of clinical medicine, in his presidential address to the British Association said that improvement in environment and life style together with better ways of delivering health care would not be enough on their own to reduce heart disease, stroke and cancer. What was needed was better understanding through basic medical research. Identifying the genes responsible for pre-disposing people to disease offers us a route to the cause and mechanism of many of our intractable killers.

Leading health experts in the US and Europe have similarly identified single specialist hospitals as the best way forward—particularly in cancer treatment and research. As my noble friend Lord Limerick pointed out, a report issued by the International Union Against Cancer in 1990 states that throughout the world the independent cancer centres, including the Royal Marsden, have been named as the most successful in patient care, research and teaching.

It will be an outrage if this country's unique centre of cancer treatment and research were to be closed, and I dread to consider the impact of such a bureaucratic decision on the lives of present and future sufferers of that dreaded disease.

I have two things more to say. I referred in my opening remarks to the personal reasons which have led a number of Peers to be passionate in their willingness to undertake any action to prevent the closure of the Royal Marsden. In my case, my daughter suffered from cancer and eventually died from that disease. I have experienced and seen the heartbreak and the hope as patients and doctors battle together to combat the ravages of that terrible disease which affects one in three of the population. I have spent days, weeks and months pacing the corridors of the Royal Marsden. Sir Bernard Tomlinson spent four hours at the Royal Marsden and the chairman of the Specialty Review Group, Dr. Christoper Paine, spent three hours. Those fleeting visits, coupled with the prejudiced and inaccurate data I have referred to, are not the basis on which the Secretary of State should make her judgment.

My second personal comment refers, as did my noble friend Lord Limerick, to the £25 million raised by voluntary donations to the Royal Marsden Appeal. I was chairman of the City and Industry Committee of that appeal and in that capacity approached business and workers throughout this country and abroad to raise millions of pounds. The chairman of the City Committee has written to me expressing the concern of institutions and individuals who had generously supported the appeal and warning that if the Royal Marsden closed, thus wasting millions of pounds, then it would be most unlikely that they would support any future appeal for a NHS hospital. If the Royal Marsden did close, I would feel, as a matter of honour, that I would have the responsibility to write to all those who had responded to my committee approaches, apologising for the Government's action. I could do no less in conscience.

What then is the way forward? I urge the Secretary of State to spurn what my noble friend Lord Peyton has described as the poisoned chalice of misinformation offered by her advisers. She should be guided by her own sound instincts when on 16th February she said in another place: After studying further information during our discussions on the Tomlinson report and further appraisals that we were able to undertake, we took the view that it was not a cost-effective option to move the Royal Brompton and the Royal Marsden hospitals to the Charing Cross site" —[Official Report, Commons, 16/2/93;col. 141.] She went on to say: We are persuaded that there is scope for the development of a Chelsea health sciences centre". The Chelsea Health Sciences Centre would link together the Royal Marsden, the Royal Brompton, the Institute of Cancer Research, the National Heart and Lung Institute, Charing Cross and Westminster Medical School, Hammersmith Hospital and the Royal Postgraduate Medical School. Sir Ronald Oxburgh, Rector of Imperial College, described that idea, which was commended in February by the Secretary of State, as a, once in a lifetime opportunity to create a grouping of medical capabilities and talent that could challenge any in the world of quality and size". The Secretary of State should be bold enough and courageous enough to grasp this opportunity which she herself so wisely identified last February.

11.45 p.m

Lord Rea

My Lords, I have listened to all noble Lords who have spoken in the debate tonight. I agree with almost everything that has been said about London's hospitals. As a general practitioner, I shall take a somewhat different line and ask about the progress that has been made in the plans for developing primary care in the wake of the hospital closures and other changes which are proposed as a result of the two reports that we are discussing.

I wish to follow up the Written Answer given by the Minister, Dr. Mawhinney, in another place on 30th November (col. 464). It was in reply to a Written Question by Mr. Jeremy Corbyn. The Minister stated that in the 12 family health service authorities in the London initiative zone—otherwise known as LIZ—£40 million would be spent on more than 100 capital schemes in the coming financial year. There would also be 31 voluntary-sector projects, at an additional cost of £5 million, to help prevent admissions or facilitate early discharge. That works out at £400,000 per capital project and £129,000 per voluntary-sector project. I should be grateful if the Minister could describe in as much detail as she can the type of project that is being financed in each category. I shall soon be tabling a Written Question asking her to name each project and to give its cost.

The new health centre in Camden, about which I know, is estimated to cost upwards of £2 million. Will the capital projects involve the completion of new health centres or will they involve merely the alteration of existing buildings? The voluntary-sector projects seem a lot more modest. The developments would be welcome without any hospital changes, but they will be unable to prevent many hospital admissions or permit early discharges without a significant extra investment in primary health care personnel. I refer to nurses and home helps in particular and to investment in more housing. It is impossible to look after an ill, homeless person in the community and difficult to look after someone living alone or with a disabled partner without labour-intensive, expensive caring services. Building up caring primary health-care teams, just like building up hospital specialty teams, is a slow process. It may not be as complex as building up a major specialty team but it takes at least five to 10 years.

Perhaps the Minister will tell us what steps are being taken to attract and retain more district nurses in London. At present, nurses having a great deal of difficulty in finding affordable accommodation. Are FHSAs to be empowered to allow GPs to be reimbursed for employing at least two, if not more, staff? Will FHSAs and community trusts pay nurses directly or in addition to the reimbursement scheme and second them to doctors?

The Question that we are debating concerns hospitals, but we must know what services will be in place in the community before beds are closed. In north-east London, most GPs are not finding it any easier to admit patients to hospitals. In Camden and Islington it has become, if anything, more difficult. The decline in patient demand which is predicted in Tomlinson and in Making London Better is just not occurring. That may be because beds and wards are being closed.

According to a parliamentary Answer given last week by Tom Sackville to Dawn Primarolo, London has lost nearly 5,000 nurses in the past year and has gained nearly 3,000 men in grey suits. I cannot see that that is helping matters with regard to looking after the needs of London's patients.

I had intended to speak briefly in addition about some of London's hospitals but it is very late. I shall confine myself to picking out one or two matters which have not been raised by other noble Lords.

Despite the fact that the retention of the accident and emergency department at UCH was recommended both by Tomlinson and in Making London Better, there has been a hint that it will be closed. I should warn the Minister that, if it were to be closed, it would leave a dangerous hole in the West End. Not only are there three rail terminals close by but the whole area is criss-crossed by Underground tube train routes. A disaster could occur at any time. The victims of the King's Cross disaster were cared for admirably by the accident and emergency department at UCH. Such a disaster could stretch a fully equipped accident and emergency service to the limit.

I hope that the noble Baroness will realise also that the proposed centre of clinical and scientific excellence at UCH Middlesex needs, as my noble friend Lady Dean said, a fully functioning acute hospital at its heart to provide a basis for teaching for clinical medical students and to provide a source for clinical research. As my noble friend said, costs can be, and have been, brought down. The hospital will be and should be trimmed, rationalised and smaller than it is now. But it should exist. Those services at any centre of excellence where teaching and research takes place are likely to be more expensive. They are in any teaching hospital. But they are more expensive because they are better staffed and better run, as they should be in a teaching hospital.

I echo the stalwart defence that was made for the retention of the Royal Marsden. The decision to move it seems to be a grave mistake.

Finally, I stress, as nearly all noble Lords have done, how important it is to preserve specialist teams of excellence which have been built up over years. Once they have gone, it is extremely expensive and takes a very long time to rebuild them.

11.55 p.m.

Lord Hayhoe

My Lords, perhaps I may begin by saying that my sympathies go out to my noble friend the Minister, who has to reply at this late hour to such a wide-ranging debate about hospital services in London. Of course, we are all grateful to the noble Baroness, Lady Jay of Paddington, for initiating the debate, though I was sorry that her contribution was not more constructive in that she reiterated the problems with which we are all familiar but did not propose solutions to them. I wondered whether the debate was going to be more about politics than health care in London and I was left in no doubt as I listened to the noble Lord, Lord Bruce of Donington, who made absolutely clear what he thought about politics in relation to the subject.

However, perhaps I may return to health care in London and declare my interest as chairman of the Guy's and St. Thomas' Hospital Trust. The trust, merging two famous hospitals, in in effect a child of Tomlinson. It was born or established eight months ago and I suppose that it might be right and proper for me to give a very brief progress report because much has been accomplished. The hospital administrations and the clinical managements have been merged effectively and economically. A unified structure is now in place and working constructively for the future. The trust's formal reponse to the Secretary of State's request, made in establishing the trust, that it should consider whether and how all its clinical services should be concentrated on one site, and whether it should retain two accident and emergency departments, was submitted by me to to my right honourable friend at the end of last month.

Our conclusion is that the retention of clinical services on both our main sites represents the best way forward for the trust, but that they should be provided in ways radically different from the current pattern. We have accepted and endorsed the view of our main purchaser that we need retain only one accident and emergency department, and we are recommending that that service, together with its appropriate support services, should be located at the St. Thomas' site. We are recommending that Guy's should develop as the major specialist, tertiary care centre in South London, building on the opportunity offered by Phillip Harris House to provide those services in the state-of-the-art accommodation, designed specifically to integrate clinical, research and teaching facilities for those services.

I should like to make it abundantly clear that our recommendation is not a quick fix or fudge, but a long-term strategy arrived at slowly and after very careful consideration of detailed analyses, largely prepared by independent consultants, and of advice, much of it conflicting, based upon strongly-held but very different convictions, opinions and interests.

The trust board's strategy has been spelt out in detail in the report sent to the Secretary of State. That strategy has the advantages and disadvantages of any consensus conclusions based upon the careful weighing and judgment of varied evidence. Like any fabric of consensus, I well appreciate that determined picking, or special pleading, can begin to unravel the woven threads, but to what purpose? I see no other pattern for progress which can command similar support or general acquiescence. Almost inevitably, continued uncertainty will bring its own harvest of conflict and controversy. There is no doubt that clinical opinion would much prefer a tidy, single-site solution—fully funded of course—but there is no similar agreement about which site should be chosen and financial considerations are evenly balanced between one site and the other. I believe anyway that any such choice—let me put it in stark and straightforward terms—between closing St. Thomas', with its well placed accident and emergency department, or closing Guy's, including its near completed phase III development (Phillip Harris House which, at £140 million plus, at current estimates, is the second most expensive hospital development in the United Kingdom, second only to the Westminster and Chelsea, which has been referred to by a noble Lord who spoke earlier) would not be for the board to make. As I have said, the matter is evenly balanced on financial and other considerations. It would be for Ministers to decide.

The trust board's strategy is not, I frankly admit, the idealistic best solution, but it is both realistic and good and, as such, has a number of important advantages. It can be achieved rapidly and much more quickly than single site solutions which would require significant extra capital expenditure. That point was referred to by the noble Baroness in opening the debate. It will keep disruption of patient services to a minimum. Perhaps more importantly, I believe it will allow the Government and the trust to achieve three major objectives in London. It will provide a distinctive and radical approach to reshaping acute care in London. One of the major criticisms of London teaching hospitals has been their inability to provide good basic local acute and emergency care alongside specialist departments. There has been a natural tendency for the latter to edge out the former. We have the opportunity to create at Guy's a world-class tertiary care centre and at St. Thomas' the highest class of care for people who live and work locally. These distinctive roles can develop within the context of a single university hospital trust. It will free space sufficient to allow the plans for the amalgamation of King's College and the United Medical and Dental Schools. of Guy's and St. Thomas' to proceed. Our solution will make significant revenue savings, for we are aiming to reduce spending overall by about 30 per cent. with job losses of similar dimensions. That is a tough and demanding objective.

My advice, therefore, to Ministers is quite clear: end the present uncertainty as quickly as possible, if not even sooner. Make your decision so that all concerned can build upon the substantial progress already made in bringing these two great and historic institutions, Guy's and St. Thomas', ever closer together.

I had hoped to turn from the particular to more general issues at this stage but perhaps at this late hour it would be wise for me to limit myself to a very few. First, I shall mention weighted capitation. I have made this point in your Lordships' House before. Tomlinson recommended an urgent review and made a number of important suggestions to improve funding for deprived areas like those surrounding Guy's and St. Thomas'. The Government accepted that a review was required and it has been put in hand. I hope the Minister will be able to indicate, if not this evening at least fairly soon, when this review will be completed, the report published, and I hope implemented, to the advantage of disadvantaged areas within the capital and other great cities in the country.

There has been much reference to specialty reviews, or at least to one of them, during the course of this short debate. There has been particular criticism of the treatment meted out by the cancer specialist review to the Royal Marsden. Without entering this dangerous area, let me say at least a word of welcome to all six reviews which recommended that their specialties should be continued or, in the case of neuro-sciences, relocated at Guy's and St. Thomas'. We thought the reviews were pretty good so far as our immediate interests were concerned.

I cannot end without commenting on and complimenting the Government on the financial settlement that they have achieved for the coming year. Treasury Ministers as well as health Ministers, so ably led by my right honourable friend the Secretary of State, have provided greater real term resources for our National Health Service at a time when pressures on public expenditure are as great as I have ever known. It is always easy to ask for more money. Indeed, all of us who have held ministerial positions have done just that in our contacts with the Treasury. But to obtain more in this year's public expenditure round is a very worthwhile achievement, and I hope that the noble Lord, Lord Ennals, who has ministerial experience of negotiating with the Treasury about health care, will join me in congratulating Mrs. Bottomley, the Secretary of State, and her ministerial team on their achievements this year.

12.5 a.m.

Lord Ennals

My Lords, the noble Lord hopes for too much. I shall not make any such statement. At the beginning of his interesting speech he implied that this may have been a political debate. There are dangers of this issue becoming a party political debate, partly because those who hold the leading posts in trusts, district authorities and other positions of authority in the health service today are found on the other side of the House or have the politics of the other side of the House. There are few with the politics of this side of the House. It is sad that that is the case.

I welcome the fact that the noble Lord, Lord Hayhoe, was so optimistic. I am afraid that I do not share his optimism. In my mind there is no doubt that health care in London is on the brink of a massive crisis. The combined effects of consistent underfunding and the commercialisation of the National Health. Service have significantly undermined the quality of health care. The Minister will say that every year more patients are treated. Every year since the National Health Service was created more patients have been treated and more funding has been provided. That has always been the case. There has not been a year when it has not happened.

Inevitably the Tomlinson Report has placed a question mark over the future of some of the great teaching hospitals and centres of excellence. Many arguments have been put forward this evening, and I am in total agreement with those who have spoken up about the absurdity of the possibility that the Royal Marsden might go when the announcement is made at the end of the review.

We ought to realise that it is not only the great teaching hospitals of Guy's, Bart's, St. Thomas', Charing Cross, UCH, the Middlesex, the Brompton and the Royal Marsden which are in a state of flux. There is uncertainty right across the health service throughout London. For example, the Ealing Hospital has an overspend of £3.2 million. The Wellhouse Trust in Barnet has a continuing deficit of £4 million. UCH/Middlesex is being supported by a temporary grant from the North East Thames Regional Health Authority. The Rush Green Hospital is closing, reducing to two the number of hospitals in Barking and Havering. There is consultation on removing all in-patient services from Barnet Hospital, downgrading accident and emergency to a minor casualty service and transferring services to Edgware Hospital. All medical and surgical beds at Orpington Hospital in Bromley have been transferred to Farnborough. Ashford Hospital in Hounslow and Spelthorne is under threat of closure. Several wards at Dulwich Hospital have been closed and the closure of the entire hospital is expected within two years. In-patient surgery at St. Charles' Hospital in Parkside has been closed, downgrading accident and emergency to a minor casualty service. Orthopaedic services have been transferred from Sutton Hospital to St. Helier's Hospital, with acute elderly services to follow shortly, putting the future of Sutton as an acute hospital in grave danger. Management at King's College Hospital has written to all staff asking them to consider voluntary redundancy. Ealing Hospital has cancelled all elective surgery for those who have been waiting less than 18 months. I could go on with a list three times as long.

There is a state of flux and uncertainty throughout the National Health Service in London. No wonder there is low morale among doctors and nurses. That is in part due to the dramatic changes to which reference has been made. We have seen a reduction of 5,000 in the number of nurses in London, with three times the number of managers. That is an appalling development. It causes great anxiety among many who work in the National Health Service.

The disintegration to which I refer has caused great concern to Sir Bernard Tomlinson. Speaking a few weeks ago, he said that the Government must step in to prevent a piecemeal disintegration of the hospital service in the face of market forces. Sir Bernard said that it would be a disaster. He said that market forces should not be allowed to destroy the planned programme of rationalisation, and called on the Government to provide special money to carry the hospitals in the interim. He said that it would be quite disastrous simply to let hospitals be destroyed piecemeal by market forces. If we are going to have to remove a hospital it has to be done in a planned way over a considerable period. Sir Bernard Tomlinson is horrified by the way in which the Government have handled the report and the piecemeal disintegration which seems to be following even without an announcement for which we have been waiting.

I believe that Sir Bernard Tomlinson was quite right. I do not know what attention the department is now paying to the wise words of Sir Bernard Tomlinson as he utters his warning. Kenneth Clarke and Virginia Bottomley have destroyed the concept of a National Health Service. That is the main consequence of the reorganisation that has been introduced with the culture of the market place, purchasers and providers, and setting one sector of the service against another.

Different levels of pay are now appearing. I have no doubt that Mr Tim Matthews, at 42 the manager of the trust of which the noble Lord, Lord Hayhoe is a chairman, is a very able man. But that he should earn £96,000 with up to £8,000 in performance related pay, plus a £20,000 car is intolerable for those others in the National Health Service who receive nothing extra for the rate of inflation. That causes a loss of morale. I do not know what the chairman of the trust has done about it. Perhaps he is happy with the situation. However, I believe that it causes great concern among those in the service.

There have also been enormous payments to external consultants. Tens of millions of pounds have been paid to firms to produce advice on this, conclusions on that, and reports and audits on the other. That has been at the expense of patient care.

The government policy of rationalisation is based on the assumption that London is grossly overbedded. I simply do not accept that conclusion. I accept that there has had to be a reduction and that there has had to be rationalisation of the teaching hospitals. We have already lost about 1,700 beds since the Tomlinson Report was published. In the course of that rationalisation waiting lists have gone up, as inevitably they would. But if Tomlinson's recommendations are to be carried out, another 2,500 beds will be closed in the London area with, I believe, disastrous results. The consequence of that would be that between 450 and 680 fewer consultants would be needed under this scaled-down service. There would be more administration, fewer consultants and fewer nurses. That is a serious point.

As the noble Lord, Lord Sharp of Grimsdyke, said, a few years back the Government made a disastrous decision to build the most expensive hospital in Britain, at a cost of about £250 million—the Chelsea and Westminster Hospital. The site was absolutely wrong and the cost was almost four times the original estimate. It is a hospital for 650 beds, not all of which have been opened, as the noble Lord said, and which the Government now say they do not need. It was sited not only at an inadequate site, because of travelling difficulties and narrow roads, but it was sited one mile from the Charing Cross Hospital. That questioned the need for the Charing Cross Hospital and, as we now know, it presented a grave threat to the Royal Marsden. I have to say that the present Minister was not involved, but I spent years trying to persuade the Government that it was an absurd decision to take, They said that there was no other alternative, so we produced another alternative. We produced a great deal of documentation as to how that could be done at a cheaper rate in a different area, so that it did not produce this absurd concentration of beds in one area. I went to see the Secretary of State, then Ken Clarke, to put the case to him. But the Government simply did not listen, they had taken the decision and it was going to stand. That was a terrible decision. The hospital would make a fine five-star hotel, and perhaps eventually it will he turned into a five-star hotel, but I do not think it has a future as a hospital.

So what should the Secretary of State now do? I hope that she takes no precipitate, rushed, cost-cutting service-depleting decisions for at least two years. I accept that certain decisions will need to be taken in order that those working in some of the great hospitals know what their future is; but I refer again to what Sir Bernard Tomlinson said. He said that by hurrying ahead and trying to achieve in a matter of months changes intended to take years the Secretary of State was allowing hospitals to disintegrate. I believe that we need, as soon as we can, to have a strategic health authority for London to look at the problems of London, not of everywhere else. It would be far better if the Secretary of State, while taking certain decisions to relieve the worries that exist in the minds of many who work in some of the specialist hospitals, would start by announcing a decision and then establishing a London strategic health authority. If the Secretary of State goes ahead now and demolishes so much of the London health service without, as my noble friend Lord Rea said, providing the primary health care services which are absolutely needed and closing hospitals before services in the community are available, I am fearful of what the situation will be, once the Secretary of State has made her Statement.

I think that the Government have dug themselves into such a deep and horrid pit that the citizenry of London will be devastated when the result comes.

12.18 a.m.

Baroness Cumberlege

My Lords, I am indebted to the noble Baroness, Lady Jay, for giving us the opportunity tonight to debate these issues. I believe that this is the first occasion in your Lordships' House, other than for Starred Questions, when she has spoken for noble Lords on the Benches opposite. I congratulate her on her thoughtful speech. I think she brings experience and insight to our counsels, not least as a non-executive member of the Kensington, Chelsea and Westminster Health Authority, which is itself at the sharp end of some of the issues we now face.

It is now a little over a year since we debated the Tomlinson Report. In my speech at the conclusion of that debate I made it clear that the Government had no intention of shelving the report as the 20 previous reports in the last century have been shelved. Most of your Lordships who spoke in that debate, even those who disagreed with some of the specific recommendations, acknowledged that its broad thrust was correct.

I do not wish tonight to repeat in too great detail the analysis which the Tomlinson Report contained, save to say that the problems which it identified have not gone away. As the noble Baronesses, Lady Jay and Lady Robson, reminded the House, parts of our capital city remain poorly provided for in terms of good community health services: GP premises, health clinics, district nurses and day centres for mentally ill people.

That leaves a gap in NHS provision and increases the pressure on hospitals. As a result, we see an alarming paradox. Despite the fact that London has one-and-a-half times as many hospital beds per head of population, it is harder for patients to get access to them. That is why, despite progress in the past year, waiting times in London are too high. The sum of £10 million is being targeted on the problem this year, but the key to reducing waiting times lies in developing better primary and community care so that patients can leave hospital to be more properly cared for closer to their homes and families. That releases beds for those on waiting lists.

As the noble Lord, Lord Ennals, illustrated, London hospitals are rightly coming under pressure to reduce their historically high costs. As the Tomlinson Report pointed out, even allowing for excess London costs, spending per inner London resident on hospital services is around 20 per cent. higher than the average for England. As in hospitals throughout the world, London needs to embrace medical advances such as day surgery to enable it to treat patients as they wish to be treated and to use fewer beds. In addition, patients from outside the capital are finding that hospitals nearer to their homes can meet their needs. As the noble Baroness, Lady Dean, said, that is in part due to London teaching hospitals whose graduates have pursued their distinguished careers in the provinces and have spread clinical excellence well beyond the confines of the capital.

With regard to funding, an issue that was raised by the noble Baronesses, Lady Jay and Lady Robson, the Government are setting aside money to ensure that the transition can be made as smoothly as possible. We estimate that the cost will be £105 million this year and there will be continuing costs in years to come. But that investment must be related to the changes that are needed. That demonstrates our commitment. But it also shows how London health services affect the whole NHS budget.

Many of your Lordships have expressed concern about weighted capitation. As people move away from the capital, it is right that the money should follow them. Despite the plea made by my noble friend Lord Sharp of Grimsdyke, the rest of the country is growing increasingly impatient at the cost of subsidising London's hospitals. Why, they ask, does London need one doctor for every 500 people when the national average is one to every 1,100?

The noble Baroness, Lady Masham of Ilton, movingly described the difficulties in bringing about change. But Sir Bernard Tomlinson warned of a "spiral of decline" if we did not act now to address the issues. That is why, when I spoke to your Lordships a year ago, I warned that "no change is no option".

Despite the late hour I crave your Lordships' patience as I set out what the Government have done in the intervening year. The publication of the Tomlinson Report itself showed that the Government are committed to a process of managed change. Although the problems which we face have been brought to a head by the pressures of the internal market—and I make no apology for that—and despite the view of the noble Lord, Lord Bruce of Donington, which was so forcefully put, it was clear from the outset that the size and complexity of the problem demanded more than the unrestrained hand of market forces.

The Government responded in February with the publication of Making London Better. That set out a clear framework for change. At the same time we set up the London Implementation Group to work through with those involved the options for reshaping hospital services and to broker change. As the noble Baroness, Lady Robson, reminded your Lordships, we also announced that further independent reviews would look at the best ways of strengthening specialist services in the capital, addressing the duplication and fragmentation. The specialty reviews concluded their work on time, three months later. I know that their findings were not universally supported, especially by my noble friends Lord Carr of Hadley, Lord Sharp of Grimsdyke and Lord Limerick. But the methodology used by the specialty review teams was the same methodology used by the MRC in its reviews, and its membership was composed of people of national and international reputation. It is interesting that it is only one review out of six which has been criticised, and that by a relatively small group of people.

The day after the reviews were published, the Guardian newspaper said in a leader that, fewer but larger centres will help to raise standards by providing a more comprehensive service. Bigger units allow doctors to branch into sub-specialties and improve their technical skills". We endorse that view. Over the next few years there will be a reduction in the number of specialty centres in London. Some will merge and strengthen; others will move out of London into areas where specialist care is not as well developed.

The noble Baronesses, Lady Jay and Lady Dean of Thornton-le-Fylde, were critical of the Government for not producing an overall strategic plan. But it was not the purpose of Making London Better to lay down a definitive and final blueprint for the future. Throughout, we have taken time and trouble to consult widely, openly and genuinely. The Government will not be deflected from what has to be done overall. But equally we wish to be sensitive and constructive towards the representations we have received. As my noble friend Lord Carr urged, we have sought to strike a balance between undue caution and unseemly haste.

There was, and is, widespread acceptance and support for what we are trying to achieve. There was, and is, a strong feeling that the time has come to grasp the nettle. There was, and is, a willingness to look imaginatively towards the future rather than remain rooted in the past.

We have succeeded in moving the debate forward. We have achieved ownership of our proposals well beyond the Department of Health. We have won new allies to our cause in the NHS and in the professions. We do not underestimate the loyalty and affection which many people feel towards institutions. But the voices urging us on are just as loud.

We have won support partly because we have shown ourselves to be serious about improving primary care. As the noble Lord, Lord Rea, said, we have committed £170 million of capital investment to that cause over the next six years. This year alone, £40 million of new money is funding over 100 new projects. That figure will increase substantially next year. The hour is too late to describe all the schemes as requested by the noble Lord, but examples are that five new centres are being built in Greenwich and Bexley; five in Enfield, Tottenham and Edmonton; and minutes from your Lordships' House there is the new South Westminster Centre for Health.

Added to that are 23 new hospital at home schemes and 31 new voluntary sector projects which are helping to prevent unnecessary hospital admissions or are enabling patients to be discharged earlier from hospital than would otherwise be the case. We are developing new community facilities for the care of mentally ill people. For example, a home nursing team has been set up in Ealing, Hammersmith and Hounslow. We have also recruited over 400 new staff—not predominantly men in grey suits, but largely health visitors and district nurses. And we are spending £2.2 million on the professional development of GPs and nurses.

Those examples give just a flavour of the huge improvements being made to the capital's primary health care. There will be more to come. In Making London Better we set out a vision for the future; we are making that vision a reality.

The noble Lord, Lord Bruce of Donington, mentioned the Mental Health Act's biannual report. That is a report we take extremely seriously. Prior to receiving it we set up a mental health expert reference group to advise us on the situation in London. The emphasis of the group will be to seek practical solutions and ensure that health authorities take full account of their responsibility to purchase appropriate mental health services in the capital.

Part of the reason why we are so determined to improve primary care in the capital is because of the beneficial impact that that will have on London's accident and emergency services. Most of us would accept that a large number of patients are obliged to seek help at their local accident and emergency unit because they feel that they have no other doctor to turn to. That cannot be right for them; nor can it be right overall for the hard-pressed accident and emergency services. I welcome developments such as those now in place at King's, St. Mary's, UCH and the Royal London as a result of which GPs are working inside A&E departments. The minor injuries clinic at St. Charles' is a further example of successful innovation in that area, and one that I believe is supported by the noble Baroness, Lady Jay.

The Government's first priority in respect of accident and emergency services must be to ensure that all those who live in, work in and visit our capital city have quick access to high quality services when they need them. I am happy to repeat the assurance given before in your Lordships' House that we shall not close any accident and emergency department unless and until we can be sure that this fundamental condition is satisfied.

I should, however, point out to your Lordships the professional advice given to Ministers, which is that annual attendance at an A&E department should be of sufficient volume to ensure the right balance of staffing, space, equipment and critical back-up facilities such as resuscitation and intensive care. Consultation on the closure of the accident and emergency department at St. Bartholomew's has recently ended. A decision is expected very shortly. A decision on the accident and emergency department at Charing Cross awaits the results of the joint study on the possible merger of the Hammersmith and Charing Cross hospitals. Our commitment to comprehensive accident and emergency coverage for the capital is not negotiable. But it is essential that the services which are provided are of sufficient quality if the best possible outcome for patients is to be achieved.

The London Ambulance Service is, of course, crucial to the equation. I fully accept that the London Ambulance Service has given rise to genuine cause for concern and it is vital that it improves its response times to the standards we expect and have laid down in the Patient's Charter. This is a matter of better management and better working relationships, but it also calls for greater investment in the service so that it can modernise and expand its facilities. The Government have invested substantially in the London Ambulance Service in recent years. My right honourable friend the Secretary of State will be saying more about how we will improve the service shortly.

Decisions about accident and emergency departments are clearly relevant to the wider decisions which must be made about hospital services. It is to specific hospital services that I now wish to turn.

Consultation and assessment on trust applications for University College London Hospitals, incorporating the Royal National Throat, Nose and Ear Trust, the National Hospital for Neurology and Neurosurgery and Great Ormond Street, will end in January, following which my right honourable friend will announce her decision. Work to consolidate services at the UCL/Middlesex site has been taken forward with the closure of the Cruciform building on Gower Street. As the noble Baroness, Lady Dean, reminded your Lordships, the hospital has also made other savings to reduce its costs, in response to the pressure exerted by purchasers. This is clearly welcome. The noble Baroness also asked where the purchasers fit into the picture. The London Implementation Group works closely with health authorities as purchasers and recognises their crucial role.

So far as the accident and emergency department at UCH is concerned, I appreciate that there is uncertainty on this front. The position will become clear quite soon.

I am aware of the very strong views and the respect and the admiration in which your Lordships hold the Royal Marsden Hospital, but perhaps I may remind my noble friends Lord Limerick, Lord Carr and Lord Sharp that Making London Better did not accept the case for moving the Royal Marsden into Charing Cross Hospital. There are no plans to close the Royal Marsden. The special health authority is currently consulting on a trust application which the Secretary of State is due to consider in January. Likewise, the Royal Brompton Hospital is submitting a separate trust application.

Consultation on a new joint trust between St. Bartholomew's, the Royal London and the London Chest Hospital has now finished. It is well known that that group is examining options for consolidating services in the long term at the Royal London Hospital site in Whitechapel. This is in line with the policy set out in Making London Better. Such moves, together with improvements to the Homerton Hospital and local primary care, form part of the Government's commitment to improving NHS services in this area of the capital.

The first phase of development work at the Homerton Hospital, at a cost of £11 million, began in June. This will enable the services currently provided at the Hackney Hospital to be moved to a far better and more modern setting. The buildings which currently accommodate the Hackney Hospital have clearly outlived their usefulness. Further improvements to the Homerton are expected to be announced shortly.

Among other things, the improvements at the Homerton, and related developments in the community, will enable substantial advances to be made in caring for mentally ill people in this part of London. To this end, the East London and the City Health Authority has made mental health services one of its key priorities this year.

As my noble friend Lord Hayhoe told us, the new Guy's and St. Thomas's Trust was set up in April under his distinguished chairmanship. The Trust Board has just completed an evaluation of its site options. The preferred option of the board is to integrate services on both sites and to reduce the size of the estate. This proposal is now being evaluated by the London Implementation Group and the trust outpost who will make recommendations to Ministers shortly.

The Hammersmith and Charing Cross Hospitals are currently considering the possibility of creating a new powerful teaching, research and hospital centre for West London, possibly on a single site. A team is taking this work forward. The possible relocation of Queen Charlotte's will depend on its findings.

A major review of hospital services in south west London is also being carried out by the. South West Thames Regional Health authority, and it will be making its recommendations to the London Implementation Group shortly. In each of these areas, the debate must move away from buildings and concentrate on the services inside them. Centres of excellence are not built of bricks and mortar but on the skills of doctors and their teams. It is this excellence which we are determined to conserve.

Let me illustrate the point by one decision already taken and warmly welcomed by the noble Baroness, Lady Robson. As she said, St. Mark's, the specialist hospital for intestinal disorders, is to move from its outdated accommodation on the City Road to Northwick Park Hospital. The move will allow the excellent clinicians at St. Mark's to develop their expertise and knowledge in more modern surroundings and with access to a wider range of services.

Staff are our greatest asset. That is why, after full and detailed consultation with the trade unions, we set up a clearing house and helpline to identify new vacancies countrywide and are matching displaced staff to vacant jobs. Already we have managed to place over a third of the staff who have registered.

I turn now to the vitally important area of education and research. These are areas where London deservedly has an international reputation which we are determined should flourish into the next century. There are several free standing undergraduate medical schools in London, each with a distinguished list of alumni. These schools will continue to thrive. However, it is widely recognised that medical students need access to strong departments of life sciences to strengthen their clinical training. The partnership of University College with the University College London Hospital is a shining example.

The Tomlinson Report proposed that these free standing medical schools should merge with established university colleges, a view which we endorse in (Making London Better. Very good progress has been made in this area under the auspices of the Higher Education Funding Council for England.

Proposals are currently being explored to merge the Charing Cross and Westminster Medical School with Imperial College, the Royal Free and UCLH medical schools as part of University College London; the London Hospital and St. Bartholomew's medical schools with Queen Mary and Westfield College, and the united medical and dental schools of Guy's and St. Thomas's with King's College.

There is also good progress in developing ever closer links between the independent postgraduate institutes and their neighbouring major university colleges. There are many details to be worked through, but we believe these measures will help maintain first class under-graduate and postgraduate education for the capital.

The noble Baronesses, Lady Jay and Lady Dean, raised the issue of research. We are determined that London should remain at the leading edge of medical research. It enjoys worldwide renown in this field and should continue to do so. A peer review of the quality and importance of research of the postgraduate special health authorities was chaired by Sir Michael Thompson, Vice-Chancellor of Birmingham University. It reported in the summer. Following this the Government announced that they would continue to provide central support over the next three years to protect high quality work. The details of the allocation will be made known shortly. I believe that the support that we shall give shows the clearest possible commitment to the capital's medical research.

I am aware that I have not done justice to your Lordships' debate and have not answered many questions, but I will read Hansard carefully and try to follow up the unanswered questions.

In conclusion, the Tomlinson Report was greeted with relief by some, by some with despondency and by some with a few tears. I recognise that it is impossible to avoid a period of uncertainty, which affects staff morale, and the Government are committed to bring that uncertainty to an end as soon as possible. In the meantime, I should like to pay tribute to the professional manner in which the vast majority of staff in London have continued to provide a quality service to patients.

In particular, I commend to your Lordships the words of Mr. Peyton Beale, a distinguished surgeon of King's College Hospital. He called for medical change to meet the needs of the population no longer living in such numbers in or near London and to address the great advances in medical science. The fact that he made this call in 1902 underlines the long-standing nature of the problem and the vital need to address it. Ninety years later Mr. Beale's call is being answered.

House adjourned at nineteen minutes before one o'clock.