HL Deb 16 February 1993 vol 542 cc1007-23

4.12 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege)

My Lords, with the leave of the House, I shall now repeat a Statement on the future of the NHS in London, which is being made in another place by my right honourable friend the Secretary of State for Health. The Statement is as follows:

"With permission, Madam Speaker, I would like to make a Statement about our proposals for improving the National Health Service in London.

"I begin by expressing sincere thanks to Sir Bernard Tomlinson. His report has been instrumental in carrying the debate forward.

"Following the publication of the Tomlinson Report we undertook an extensive period of informal consultation with the institutions and professional groups involved. I pay tribute to my honourable friend the Minister for the thorough way in which he held those discussions.

"London and the rest of the country are poorly-served by the present pattern of health services in the capital. Despite the fact that we spend some 20 per cent. more per head in London than elsewhere, services are often ill-matched to the day-to-day needs of those who live and work there.

"London has 43 major acute hospitals; twice as many consultants per head as elsewhere, and, for example, 14 centres of specialist cardiac services and 13 in neurosurgery.

"Despite the panoply of provision, patients use accident and emergency departments rather than going to a GP. Patients cannot be discharged from hospital because there are inadequate services outside hospital to care for them. Primary health care services in the rest of the country are often well ahead of the care available inside London.

"This is an unacceptable imbalance. It has to be redressed. The issues are well-known. They are well-documented and well-understood. They have been the subject of at least 20 reports in the last 100 years. For a variety of reasons, successive governments have declined to grasp the nettle. Today we are making a decisive break with that tradition.

"Patients from outside London prefer to be treated locally. This process will accelerate, not decline, in the future. Modern medicine means also that we can treat more patients with fewer beds. Many more services can be provided outside hospital, as the pioneering advances of the GP fundholders in particular have shown. London should be in the vanguard of change.

"Our response is rooted in the principles of our health service reforms. We start from the unshakeable belief that in London, as elsewhere, it is the patient who must come first. How and where services are provided should be determined first and foremost by what suits their patients.

"To provide a patient-focused, modern health service in London requires a radical programme of change. The work will be carried forward by the London Implementation Group, reporting to me, and working with the existing health agencies in the capital. It will start now, work quickly and keep to a strict timetable.

"The first step has to be a substantial improvement in primary care in London. This means the development of higher quality, more accessible health services at local level—provided through GPs, nurses and other professionals in the community.

"I am establishing today a London initiative zone covering the most deprived parts of the city where services can be most improved. I will be providing £170 million capital investment over the next six years for improvements in the LIZ area. Much of this money will be used to provide new and improved premises for GPs and their teams where they are needed and to provide new primary care centres.

"Next year alone, we will invest over £40 million additional funds in primary and community health services. In addition, a further £10 million will be specifically targeted to ease waiting time problems for inner-London residents.

"We will strengthen the training of family doctors, nurses and other professional staff. We will bring experienced GPs into the capital, perhaps on short-term appointments.

"We will be looking at new ways of providing services: by employing some GPs directly; by reviewing relevant aspects of the GP contract, such as the system of deprivation payments; by developing the GP fundholding initiative in London which has brought so many benefits to patients elsewhere and by much else besides.

"We expect the social services to play their full part in ensuring effective integration of local health and social services. They must make use of the opportunities provided by our community care reforms, and the significantly increased resources available through the special transitional grant.

"We also want to make best use of the special skills and talents of the voluntary sector. I can announce today that I am making a further £7.5 million available over the next three years to build up the role and work of the voluntary organisations.

"To focus on innovation and experiment, we will provide £1 million to initiate a new London Primary Health Care Challenge Fund. We look to others also to contribute to the fund. It will make money available, on a competitive bidding basis, to fund experimental schemes, especially those which aim to bring local and hospital care together and those involving the voluntary, independent or social services sectors.

"Putting these ideas into place involves a shift from care in acute hospitals to primary care. This in turn means building up services outside hospital, with fewer hospital beds and fewer sites where acute hospital care is delivered.

"We need to reduce the excessive duplication of specialist services. I am announcing today six simultaneous reviews of these services, to help us determine where best to concentrate specialist services to provide high quality cost-effective care. Each review will be taken forward urgently under the joint leadership of a distinguished clinician and a senior NHS manager of a purchasing authority. They will report by the end of May.

"Accident and emergency services will mainly be provided from fully-equipped departments which have good access to back-up specialist services. In addition, we envisage an increasingly important role for minor injuries clinics.

"But there is also a case for some rationalisation of accident and emergency services. In particular, the regions are setting in hand consultation on the closure of the A&E at Charing Cross when the new Chelsea/Westminster is available, and on the closure of full-scale A&E at St. Bartholomew's.

"We are determined that the London Ambulance Service should continue to make progress, to deliver a much-improved service for the considerable sums of money invested in it.

"The new Chelsea and Westminster Hospital is one of the most modern and advanced hospitals in Europe. This £200 million development is further proof of the Government's commitment to the National Health Service in London. Its completion marks the beginning of a new and better pattern of services in this sector of London.

"A great deal of work has been done, in addition to the Tomlinson Report. On the basis of the information before me, I have decided that there is no financial case for relocating the Royal Brompton and Royal Marsden Hospitals to the Charing Cross Hospital.

"This decision has clear implications for the future of that hospital. I have asked for detailed proposals for its future to be drawn up by the autumn. The London Implementation Group will also consider where best to relocate the maternity services currently provided at Queen Charlotte's Hospital.

"We cannot sustain extensive overlap or duplication in this part of London. In the long run an integrated health sciences centre embracing the Royal Brompton and Royal Marsden, their respective institutes, the Chelsea and Westminster with links to Imperial College may be the best way forward. We will pursue this idea with these organisations.

"In south-east London, consultation is under way on the proposal to merge the management of Guy's and St. Thomas'. If a Guy's/St. Thomas' Trust is established, we will ask the new trust board to bring forward proposals, within six months, for consolidating the hospital services.

"We also propose that the University College and Middlesex Hospitals should continue to work up a proposal for rationalisation as quickly as possible. This would be considered with other priorities and subject to statutory consultation in respect of service changes. A development considerably smaller than the current hospitals combined seems likely.

"In the east of London, significant changes are needed to provide a better pattern of services for the local population. People in Hackney and the surrounding area will be best served by developing the Homerton Hospital to meet their needs. To facilitate this development, the Homerton will be established as a separate directly managed unit, with a view to it offering its patients the benefits of trust status from April 1994. We will consider urgently the proposal to build a further phase of the Homerton.

"We believe it will be in the best interests of local people if some of the acute services currently at St. Bartholomew's at Smithfield are re-located to the Homerton. The hospital at Smithfield cannot continue as it is, a fact which is well-recognised, not least by the management and clinicians at St. Bartholemew's itself. Its precise future must depend crucially on the outcome of the specialty reviews and on whether or not purchasers wish to send their patients to it. In view of this, I have decided that the Bart's NHS trust should not come into operation on 1st April and is therefore to be dissolved.

"There are, in our judgment, three options for the future of St. Bartholomew's. The first is closure of the hospital site at Smithfield, with its specialist services relocating elsewhere. The second is joint management of St. Bartholomew's and Royal London Hospital. The new management would be responsible for determining whether, in light of the demand for its services, the combined hospital can continue operating from two major acute sites. The third is retention of Smithfield as a much smaller specialist hospital.

"I have set in hand an urgent appraisal of each of these options, to be concluded by the autumn. The proposal which emerges will, of course, be subject to statutory consultation. Under any of the options, the services provided at Smithfield, and the number of beds, would be substantially reduced. I propose to consult separately on whether to replace its full scale A&E department with a 12-hour weekday minor injuries unit.

"The Government will also consult on proposals for the merged management of Northwick Park and St. Mark's, and, subject to a sound business case being made, the relocation of St. Mark's to Northwick Park.

"On medical education, Professor Tomlinson's proposals for mergers of London's free-standing medical schools with the major colleges of the University of London have been widely supported. They are in line with the university's long-standing policy. My right honourable friend the Secretary of State for Education has welcomed Sir Bernard's broad conclusions on education and research. He has asked the Higher Education Funding Council for England to take them forward, working with those involved, to ensure that health and education changes march in step. The funding council will consider the issue raised in the Tomlinson Report about student numbers in London.

"Our proposals will have significant implications for NHS manpower in London. We will make sure that their skills are kept within the NHS, by redeployment and retraining wherever possible. I intend to establish a clearing house to help those staff who cannot find alternative employment through the normal arrangements.

"Madam Speaker, the Tomlinson Report made clear that the root cause of London's problems is not a lack of resources. Indeed, honourable Members from outside the capital often point to the consequences for their constituents of the fact that 20 per cent. of NHS resources are spent in London on 15 per cent. of the population.

"A top priority must be to make the NHS in London more efficient and effective. At the moment, we provide bridging funding to London hospitals to help them survive the loss of income they face from the fact that money is following the patients elsewhere. This is not a sensible long-term use of funds. It is unfair to London and unfair to the rest of the country. We will tackle these inefficiencies. Over a period of time this will mean more money for better services outside London.

"I have not the time to describe every proposal I am announcing today. Full details are contained in a document, Making London Better, published today, copies of which are available in the Vote Office. No change is no option. Sir Bernard Tomlinson spoke of a 'spiral of decline' if we do not act now. The programme of improvement must be balanced. Rationalisation of hospitals services must be placed alongside the complementary build up of services outside hospital.

"London deserves a first-class primary health care service, fit for the 21st century. London deserves a better-balanced hospital service targeted on patient needs. London deserves the radical overhaul which, over the years, many have promised but none has delivered. Under our proposals this is what London will get. We have accepted the need for radical change. We will deliver it. My programme offers the opportunity to cure London's ills and make London better. I commend it to the House."

My Lords, that concludes the Statement.

4.28 p.m.

Lord Desai

My Lords, first, I thank the noble Baroness for repeating the Statement made in another place by the Secretary of State for Health. I thank her also for making available to me the document Making London Better so that I could make use of it in my comments on the Statement.

In the newspapers there has been a great deal of hide-and-seek about what will be in the Statement. While we have not quite received misinformation, there have been many variations about which hospitals will or will not be closed.

Before I come to the detail of the Statement, I should state that it is still my opinion, as I expressed it when we debated the Motion in the name of the noble Lord, Lord Annan, a few weeks ago, that the twin problems in London are, first, the lack of primary health care facilities and, secondly, the state of London's hospitals.

Those problems arise from the nature of the internal market. In my opinion the problem of the internal market has not yet been properly addressed. The problem is not that there is a purchaser/provider split—that is fine—but that there is uniform pricing for each kind of treatment. Because costs will be higher in any inner city area compared with an outer city area, inner city areas will suffer from the internal market. An attempt has been made to come to terms with that. As we shall see later, there has been a gradual decline in the management of London's hospitals. Unless the Government think carefully about the problem of differential pricing, those problems will occur in Manchester, Birmingham and other inner city areas. The problem is that a restaurant meal in London costs more than a restaurant meal outside it. If all restaurants had to charge the same, restaurants in London would go out of business. The same applies to London hospitals. That is the problem.

Along with the problem of GP fund-holding, we have the fact that the general practitioners do not have the incentive to follow their patients' preferences. They follow their own preferences and would seek a treatment centre which is better for fund-holders than consumers. The purchaser is not the consumer and therefore it is not always possible to satisfy the consumer's preferences: it is the purchaser's preferences that are satisfied. So that is our problem and we have to come to terms with it.

Let me now direct my remarks to primary health care. We are told in the Statement that the London initiative zone will be established, and we welcome that. We are also told that a capital investment of £170 million will be provided over the next six years. My first and most important question is: is this new money, or is it money which has been top-sliced from the NHS budget so that other regions in the country will lose in comparison with London? Of course we should like this money to be new money because under the changing arrangements for per capita fund-holding, London as a region has been losing NHS money in any case. Is this new money which is coming back to London or is it money that is being taken away from somebody else?

Further, we may ask: is this money enough? We know that the King's Fund estimated £250 million as the necessary amount. The shadow Secretary for Health in another place has calculated that, if we really want to upgrade all the GP facilities that need upgrading in London, the cost would be more likely to be £400 million. I question whether that will be enough money. Perhaps a more important question is: is this all the money there is, or will there be more coming from under another heading? For example, if we are to recruit GPs from outside the capital or if that recruitment is to be improved in other ways, will there be any extra money for recruiting them, as well as for capital investment in GP facilities? We would like to know the answers.

A reference is made in the Statement to the role the social services are expected to play in the effective integration of local health and social services. We know that under the new arrangements for care in the community the amount of money under that heading is not sufficient. Also in certain crucial aspects, such as money available for treatment in relation to drugs and alcohol, non-ringfencing will make things even more difficult rather than less difficult. I wonder whether there will be any different arrangements as a consequence of this Statement.

I must say that I was somewhat amused by this primary health care challenge fund. I have heard the city challenge experience floated before, but it was abandoned because it was not very successful. This is a city challenge mark 2. That does not have as much money, as the previous one, but I assume that we can go on trying until one succeeds. The Statement says that we are looking to others to contribute to the fund. I should like the noble Baroness to tell us who the others are. Is this an invitation to privatisation of primary health care in London or will somebody else give the money?

Turning to hospital reorganisation, I have one comment. No doubt other Lords will comment on different hospitals. It still remains the case that the background will be a steady shrinkage of hospital facilities in London. Although I welcome the retention of the Royal Brompton and Royal Marsden Hospitals—close to the hearts of many of your Lordships—if we go into the detail of the document, Making London Better, in paragraph 62 on page 12 it clearly says that the Government expect the Royal Marsden and the Royal Brompton to contract as a result of the internal market. If there is to be a contraction of this joint hospital over the next few years, one would like to know the timetable of that contraction and how it will be managed.

One would have the same sort of feeling about St. Bartholomew's. I am sure that many noble Lords would like to comment on this, but I simply say that there seem to be fragmented strategies of dealing with that hospital. I would welcome a clear decision now rather than in a few months, but if there is to be a decision, it would be good to know how quickly the noble Baroness thinks that the problem with this hospital will be clarified and what the consequences will be for the staff there. One background factor as a consequence of the internal market is the proposal regarding the special health authorities and the internal market. This has not been mentioned, but I should like to ask the noble Baroness to explain to us how she envisages the role of the internal market and the special health authorities.

Lastly, I should like to ask the noble Baroness about the consequences for the staff concerned. The Statement mentions in paragraph 38 that a special clearing house will be established to help the staff. Do the Government envisage redundancies? If so, what is their estimate of the numbers involved? The longer document mentions redundancies but there is no mention of them in the Statement and one would like to know how that matter will be dealt with. I—

Baroness Trumpington

My Lords, I do apologise to the noble Lord. I know that this was a very long Statement but I have been looking up in the little red book. Comments are meant to be brief, and I would point out that the noble Lord has been talking for 12 minutes. I would not in any way wish to stop him, but I wonder whether he could do a sort of "shorthand" for the rest.

Lord Desai

My Lords, I thank the noble Baroness. I am just about to finish. I will give a cautious welcome to the Statement, but much anxiety remains.

Lord Winstanley

My Lords, I personally should like to go a little further than the noble Lord, Lord Desai, and not merely thank the noble Baroness for repeating this important Statement, but also to thank her for the extent that she may have been responsible for the content of the Statement, much of which has been warmly welcomed by my colleagues on these Benches. I particularly welcome some of the matters to which the noble Lord, Lord Desai, has referred.

In paragraph 11, the Statement says: The first step has to be a substantial improvement in primary care in London". I certainly say, "Hear, Hear" to that; but my fear—one that I expressed when we had a short debate on the Tomlinson Report some time ago—is that although everybody agreed that there had to be an improvement in primary care in London, that would have to wait until the money had been saved as a result of the hospital reorganisation. This Statement clearly seems to say that the first step is to be a substantial improvement in primary care in London: in other words that does not have to wait until all these difficult decisions about hospitals have been taken and until whatever money can be saved has been saved. The noble Baroness referred to the London initiative zone and what would be done as a first step. The Minister will be providing £170 million of capital investment. The noble Lord, Lord Desai, asked whether that was new money. There is some more new money I think in the next paragraph—over £40 million additional funds are to be given to primary health services. Is this new money?

I also ask, as did the noble Lord, Lord Desai: is it enough money? Different estimates have been made; and there is no doubt at all that a very substantial number of general practitioners' surgeries are below a standard which should be regarded as acceptable in other parts of the country. They are regarded as acceptable in London because that is the only way they can get general practitioners to work at all; and it certainly is not acceptable to me. So I should like to know about that.

One specific question arises from that part of the Statement. The Statement continues: We will be looking at new ways of providing services: by employing some GPs directly". General practitioners are not employed; they are independent contractors with contracts with family health service authorities. In the previous debate that we had on the subject, I mentioned that the Government had set an example by saying that in areas where patients cannot find a dentist to give them dental treatment under the National Health Service, the department would appoint a salaried dentist in that area to do National Health Service work. Is that what is meant here? Are the Government going to appoint a salaried GP in certain areas, for example, to treat the homeless or people who are unable to get on a doctor's list for some other reason?

Most of the excitement about the Tomlinson Report has concerned the hospitals. That is the glamorous aspect and what all the argument has been about. I believe that the noble Baroness will agree with me that it is impossible to achieve the highest standards of excellence in every specialty of medicine, however narrow, in every hospital. Not only is it impossible, it is nonsensical and wasteful to attempt it. That is what London hospitals have been trying to do. They have all tried to do everything. That is not the way in which we should proceed. There are certain extremely expensive specialties in medicine at which we are becoming very good indeed; but there is no reason why they should be undertaken everywhere. Some only need to be undertaken somewhere, as long as they are carried out, and in sufficient quantity, and as long as everyone knows where they are carried out.

That is one of the problems. When casualty departments close, nobody tells anybody. Not a day goes by when a taxi does not take an injured person to the casualty department of a hospital which has in fact not had one for two or three years. But that has not been sufficiently well advertised. As a doctor attending noble Lords and Members of the other place, I had the embarrassing experience some time ago of attending the wife of a noble Lord who had suddenly suffered from a detached retina. I sent her rapidly to a hospital only for her to find that when she arrived there the ophthalmic department had been closed. Once changes are made and there is rationalisation, it is very important that publicity is given to the changes so that everybody knows where everything is, what services are provided and where.

I see that the noble Baroness is looking at her watch. I shall be as quick as I can and I shall finish in a moment. In a sense, the decision on Bart's has been postponed. The noble Baroness said that there are three options for the future of Bart's. I have set in hand an urgent appraisal of each of these options, to be concluded by the Autumn". I should like to ask her a question, of which I have given notice. Somebody whose advice I value—sufficiently to allow him to operate on me recently—has told me that Bart's is built on a Roman site of vast archaeological importance. Is that true? I am told that if it is true, then if Bart's is pulled down the site could not be sold and used for something else. That is a relevant question, and I should like to know the answer to it.

The Statement includes proposals concerning implications for manpower and making sure that skills are kept within the NHS by doing this, that and the other. The important point is not what is intended for the future, but what is done now. Consultants are already leaving certain hospitals where there is uncertainty about their future. The Government must ensure that consultants and people with great skills are not lost to the National Health Service. Efforts must be made now to make sure that they do not feel anxious and feel that they must depart and go abroad, as many are. Unless steps are taken now—not the steps which the noble Baroness says that she intends to take—we shall lose some doctors and we shall regret their loss. Otherwise, I warmly welcome the Statement, so far as it goes. We shall hear much more later.

Baroness Cumberlege

My Lords, perhaps I may reply first to the noble Lord, Lord Desai, on the question of the internal market. We do not accept that the decline in London services is due to the internal market. The decline in London has been taking place for many decades. Indeed, in the past 10 years London has lost over 5,000 beds. The tragedy has been that they have been lost in a piecemeal fashion so that we are still running very inefficient hospitals.

The costs in inner London at present are subsidised by the rest of the country, to the tune of £50 million in the current year. We expect that the figure will be greater next year. It is the subsidy which makes London competitive, and it absorbs the inner London weighting and the other on-costs.

The noble Lords, Lord Desai and Lord Winstanley, asked about the funding of primary care Primary care money for the coming year—£43.5 million—is additional money. In future years we will invest £170 million in primary care over six years, and clearly the source of that money will depend to some extent on the expenditure round. For personal social services in inner London there will be £30 million new money from the special transitional grant.

In relation to challenge funding, in my experience challenge funding stimulates a great many ideas and introduces innovation. We believe that it is the way forward to stimulate people to think along new lines. We are aware that there are a number of charitable bodies and institutions in London which wish to give to the National Health Service. Traditionally, they have given to hospitals and buildings in terms of investment in bricks and mortar. We want to change that. We want to change the whole shape of the health service in London so that it is driven by primary care. That will give those people, institutions and organisations an opportunity to do that.

Finally, I should like to pick up the point on staffing. Unfortunately I cannot be specific about the number of redundancies. Of course it is our wish that there should be as few compulsory redundancies as possible. That is why we shall invest in retraining, in the clearing house and in other measures. Clearly, however, there are too many decisions still to be made in the autumn for it to be possible at this moment to say what the exact shape of the acute services will be for the next few years.

4.47 p.m.

Lord Boyd-Carpenter

My Lords, is my noble friend aware that many of us are delighted that the Government have rejected the recommendation of Sir Bernard Tomlinson to close the Royal Marsden and Royal Brompton Hospitals? Many of us would like warmly to congratulate the Secretary of State on her very sensible decision to keep those wonderful hospitals going. I add in parentheses that I have particular reason to have a high regard for the Royal Brompton Hospital because a year ago my wife was looked after there splendidly during a severe illness. I have seen the hospital in action and, as many of your Lordships know, it is one of the great hospitals of the world.

In that context, I am sure by accident, the noble Lord, Lord Desai, when putting his question said that it was recommended that those two hospitals "should" contract. If the noble Lord looks at the paper he will see that it does not say that. It says that they "may" contract, and that is profoundly different.

In general, is my noble friend aware that we realise that the Government have an extremely difficult situation to handle and that our confidence in the Secretary of State, and in the noble Baroness, has been greatly enhanced by these decisions?

Baroness Cumberlege

My Lords, I thank my noble friend for his gracious comments. I shall relay to my right honourable friend the Secretary of State your Lordships' pleasure at the retention of the Royal Marsden and Royal Brompton Hospitals. My noble friend is right. For the first time ever the special health authorities will be facing competition from within the internal market. It is true that they may contract. It is also true that they may expand. That will depend entirely on how purchasers value those services and whether they wish to purchase them for their own populations.

Baroness Jeger

My Lords, in relating the population of London to expenditure, has the noble Baroness taken sufficient notice of the daytime population, and the enormous influx of commuters who make heavy demands especially on emergency services?

I hope that the noble Baroness will forgive me but I did not hear her say anything about the future of the Royal National Throat, Nose and Ear Hospital, which was most dismissively pushed aside by Tomlinson with a suggestion that it was so bad that it should be shut down. I believe that she has received a document from the trust of that hospital entitled, The Myths of Tomlinson. I hope that she takes note of what the trust said.

Baroness Cumberlege

My Lords, yes, the commuter population has been taken into account in the figures that I gave.

With regard to the Royal National Throat, Nose and Ear Hospital, the proposal is that the regional health authority should consult on the merged management of that hospital with the UCH and Middlesex; and that it should initiate that in May. It will be subject to consultation and then the Royal National Throat, Nose and Ear Hospital will be able to have its shout and tell us its views on that.

Lord Peyton of Yeovil

My Lords, does my noble friend agree that it is a pity that a Statement should generate such long, wide-ranging speeches from the Opposition Front Benches? Perhaps I may echo what my noble friend Lord Boyd-Carpenter said: that relief is widespread that the Government have had the wisdom to reject the quite extraordinary proposal to relocate the Royal Brompton and the Royal Marsden in the Charing Cross Hospital. I do not know whether it is fair to ask her the source of that original advice. I have always suspected that it did not originate from Sir Bernard Tomlinson but from the North West Thames Authority.

Baroness Cumberlege

My Lords, the advice to keep the status quo as outlined in the report has come from many sources, not least from noble Lords who were vociferous in their campaign to ensure that the Royal Marsden and the Royal Brompton were kept as an entity. I am afraid that I am not entirely sure where the original advice came from that they should merge and be housed in the Charing Cross Hospital.

Baroness Robson of Kiddington

My Lords, I join my noble friend Lord Winstanley in thanking the Minister for the Statement, which is heartening to all of us involved in the health service. I am particularly pleased that the emphasis is on improved primary and community care, as stated at the beginning of the Statement.

With regard to the London initiative zone, we welcome the £170 million, although that may not be enough. Will next year's allocation of £40 million be part of that £170 million? I presume that it is not an extra £40 million. It will take six years to implement the improvement of community care. I therefore urge on the noble Baroness that excessive closure of London hospital beds before the community services are in place would create tremendous dangers.

Lastly, I thank the noble Baroness for including the relocation of Queen Charlotte's Hospital and Chelsea Hospital among the reviews. Those hospitals are particularly near to my own heart.

Baroness Cumberlege

My Lords, we shall be investing heavily in primary care before the closure of hospitals takes place. That point has been made strongly in your Lordships' House and the Secretary of State and her Ministers have taken it on board.

Lord Annan

My Lords, I congratulate the noble Baroness on the fact that, despite press reports, the Statement is not a total surrender to vested interests. Perhaps I may now ask her some questions.

First, there is a deafening silence even in Making London Better about medical education and medical schools. For instance, only one of the UCH and Middlesex sites is to be used. Yet many additional services are to be put on that one site. What is to happen to the clinical teaching on that site? As the noble Baroness knows, the pre-clinical school at UCH is pre-eminent. Are the clinical students to be spread among the Royal Free Hospital and various other hospitals in North West London?

The same question applies to the St. Thomas', King's and Guy's consortium. Can the noble Baroness give us any encouragement that one of those sites south of the river will be used for educational purposes, perhaps not merely medical educational purposes?

Will the noble Baroness also enlarge on the teaching arrangements of the Royal London and Queen Mary hospitals? In her various options for Bart's, has she made some arrangements for a change in the present educational experience in those areas?

Baroness Cumberlege

My Lords, the proposals outlined by the Government today are largely in line with those proposed by Professor Tomlinson in his report. There is overwhelming acceptance that there is a need to tie in the medical schools with the University of London and the various colleges. The configuration is very much that which was set out, and has been warmly welcomed in particular by the University College and Middlesex Hospitals. It is our intention that clinical teaching should continue to take place somewhere within that area on that site.

With regard to St. Thomas', King's and Guy's, I can give the noble Lord an assurance that there will continue to be medical education south of the river in addition to that at St. George's Hospital.

Lastly, on Bart's, I know that much concern was expressed in your Lordships' House about the Charterhouse site, research and everything that was happening on that site. The Government intend that that should remain as it is now.

Lord Hayhoe

My Lords, I welcome the general thrust of the Government's response to Tomlinson, in particular its emphasis on the provision of improved primary care in the inner city. I have a personal and special interest in the proposed merger of Guy's and St. Thomas'. Does my noble friend agree that the future of those two great teaching hospitals is inextricably intertwined with the United Medical and Dental Schools, the Nightingale and Guy's nursing school and the proposed merger with King's College? Therefore, any meaningful site appraisal must take account of both the clinical and educational issues involved.

Will my noble friend confirm that Tomlinson recommended a review of weighted capitation? Will that be undertaken urgently? I judge that the present system almost certainly underestimates and short changes the health needs of those living in deprived inner city areas.

Since we often talk of value for money in the context of the National Health Service, does my noble friend agree that we receive astonishingly good value for the money we spend on our National Health Service? It is almost certainly better value for money than anywhere else in the world. We should pay tribute to the staff involved in providing such splendid service.

Baroness Cumberlege

My Lords, perhaps I may say to my noble friend that I believe that the embryonic trust could not be in safer hands. I am delighted that he is helping to guide it through.

On the question of education, I am in some difficulty because clearly a lot of those matters are the responsibility of the Higher Education Funding Council for England. Therefore, it is important that they are drawn into all the decisions that are reached.

With regard to weighted capitation, I know that there has been a lot of discussion as to whether the current system based on standard mortality ratios is fair and whether one ought to introduce a deprivation payment as well, weighted accordingly. I believe that at the moment a working party is considering that.

Finally, I wish to associate myself with the views expressed by my noble friend on the good value, dedication and commitment of staff in the National Health Service. I believe that it is the best in the world; I believe that it is the envy of the world.

Lord Bruce of Donington

My Lords, the noble Baroness may be aware that I commenced my parliamentary life in the Ministry of Health 47 years ago. She will know that I fundamentally disagree with the whole concept of the market in the health service. Nevertheless, I wish to thank her for her Statement.

I wish to ask her one general question and one particular one. Will she agree that the whole process upon which she has embarked represents a levelling down of the service rather than a levelling up? Will she further agree that her statement that over a period of three years the reforms will mean more money for better services outside London of necessity implies that there will be significant financial savings within the London area? Can she give the figure which the department has in mind for the economies which she proposes to make or the economies that will result?—that is, without taking into account for the moment both the capital expenditure that she has already mentioned and the capital receipts that may result when certain sites are evacuated for the benefit of property developers.

Will she also answer a further question? There is a slight differentiation in her Statement between her treatment of St. Thomas' and Guy's, where she refers to a management consolidation, and her treatment relating to Northwick and St. Mark's where a definite physical separation is involved. Will she confirm that the facilities at St. Thomas' and Guy's will physically remain there, bearing in mind that St. Thomas' in particular may have a future association with Members of this House and another place when they fall slightly below par in health?

Baroness Cumberlege

My Lords, I am aware of the distinguished career of the noble Lord, Lord Bruce. I live in hope that over time I shall persuade him as to the merits of the internal market. I do not believe that it is a levelling down of the service; I believe that it is a levelling up. One only has to see how many more patients are treated year on year and the work that is being done by GP fund-holders in bringing more hospital and acute services into the community where we know people want to be treated, to appreciate that.

I cannot give the noble Lord accurate figures regarding the financial savings. Clearly, the Government are determined to be efficient and effective in terms of providing health care, but I have to say to your Lordships that that is not the prime motivation for the changes in London. The prime motivation is to give Londoners a better service which we believe they have for too long been denied.

Finally, on the question of St. Thomas' and Guy's Hospitals, the proposal is that there should be consultation, which is going on now, for a trust. If, at the end of the consultation, a decision is taken that a trust should be formed, then it is up to the trust to bring proposals to the Secretary of State regarding future facilities. I think it unlikely that there will still be two sites, but it is important that the trust board looks at all the detail and comes forward with a recommendation to the Secretary of State in the autumn.

Lord Mackay of Ardbrecknish

My Lords, I congratulate my noble friend and her right honourable friend the Secretary of State on being prepared to face down the special interest groups which are obsessed by hospitals and sites in the city, and to give special preference to improving primary health care in this city. It has for a long time received the poorest quality of primary health care anywhere in the United Kingdom. If she and any noble Lords are in any doubt as to the good sense of our proposals regarding health care, perhaps I may invite my noble friend to discuss with her noble friend, the present Minister of State at the Scottish Office, whom I see on the Bench behind her, the wisdom of the policies of previous Scottish Ministers with responsibility for health in putting money into primary health care, building new facilities for the community, bringing together single-handed practices in groups, and in very many ways concentrating health care for ordinary folk at their GPs' surgeries, rather than through accident and emergency services in hospitals.

Baroness Cumberlege

My Lords, I very much support my noble friend's view on the primacy of primary care. As always, we have much to learn from Scotland.

Baroness Jay of Paddington

My Lords, like many other noble Lords who have spoken, I welcome the emphasis in the Statement on primary care which many of us have been urging for some time. As the noble Baroness may be aware, one of the problems of organising primary care in London is the fragmentation of the mechanisms. Can she be more explicit about the way in which the London Implementation Group will work? Will it have executive authority? Will it become in effect a pan-London regional health authority? How will primary care relate in management to the London Implementation Group in terms of the London initiative zone? Will they be coterminous? Coterminousity has been one of the problems with which those of us who have been working in London have battled for a long time.

I raise one further point on the new funding. In pursuance of what the Minister said in reply to the noble Baroness, Lady Robson, can she expand slightly on the new money which will be available? Is the new money to be given immediately to be the only new money, with the rest being taken out of the regional budgets in the next few years?

Baroness Cumberlege

My Lords, I believe that I have 30 seconds in which to answer the question. On the subject of the London Implementation Group and how it relates to the management of the health service, particularly the London initiative zone, perhaps I may refer the noble Baroness to the report which came out today, Making London Better. It is clearly put there in the appendices.

With regard to the funding, there is nothing further I wish to add, except that the £43.5 million will be available for London healthcare from 1st April this year.

Lord Howell

My Lords, in the seconds that are left, I should like to ask the noble Baroness about the accident and emergency cover for Westminster. I could not entirely comprehend that long Statement, but it contains the prospect that we may lose Westminster, St. Thomas', University College Hospital, and Middlesex Hospital. Where on earth are people to go in an emergency in the district of Westminster?

Further, may we be told that the Westminster Children's Hospital will be amply replaced, if it has to close? It is a unique service and needs to be kept together, with sufficient beds to maintain the service now given to the nation at Westminster.

Baroness Cumberlege

My Lords, I am in penalty time, so I shall be brief. I just wish to say that people who at the moment attend the accident and emergency department at the Westminster Hospital will in future go to St Thomas' or the new Chelsea and Westminster Hospital which has just opened.

Lord Howell

My Lords, what about Bart's?

Baroness Cumberlege

My Lords, in this city we have 11 teaching hospitals with accident and emergency departments within a six-mile radius. No other city in the world has so many hospitals with so many A&E departments. I regret that I forget the second part of the question.

Lord Howell

The children's hospital.

Baroness Cumberlege

My Lords, that is also being moved into the Chelsea and Westminster Hospital.