HL Deb 21 October 1993 vol 549 cc655-67

4.35 p.m.

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

My Lords, with the leave of the House, I should like to repeat a Statement which my right honourable friend the Secretary of State for Health has made in another place. The Statement is as follows:

"With permission, Madam Speaker, I wish to make a statement about the management of the health service in England. Our health reforms are now firmly in place and here to stay. From next April, 90 per cent. of acute and community health services will be provided by NHS trusts. Patients are already benefiting from the freedom to innovate and improve which we have given to NHS trusts, to GP fundholders and to local health authorities. By passing responsibility down to local level, we have released the innovation and energies of those working nearest to users of the service. The result has been a fundamental shift of power towards the patient.

"The priority now is to support better patient care through the continued drive towards decentralisation in the NHS. I have concluded that to do this requires changes to the management structures of the health service—structures which are largely unchanged since before the reforms. By streamlining management, we can also make substantial savings in administrative costs. These changes will maximise the proportion of NHS expenditure devoted to direct patient care.

"My proposals for achieving these objectives are set out more fully in a background paper, copies of which are in the Vote Office. They follow the functions and manpower review which I announced to the House in May. I should like to place on record my thanks to Kate. Jenkins and Alan Langlands, who led the review, and to their team, for the work they undertook.

"A guiding principle of the review was that change should support the development of the all-important purchasing function. This function is now the distinctive role of district health authorities. Their job is to build up an accurate picture of what health services local people need and to purchase services which best match those needs. Like GP fundholders, they have the power to change and to improve services. They lead the drive towards better quality care and better health in their areas.

"A key feature of better purchasing is closer working between district and family health service authorities. It makes it easier to take an all-round view, to strike the right balance between hospital and community-based care and to improve public health. These authorities are already working in close partnership in many areas. We wish actively to encourage this. I therefore intend, subject to Parliament's consent, to introduce a power to enable district and family health services authorities to merge. Such mergers will also eliminate duplication and produce savings in overhead costs which can be spent directly on patient care.

"This will build naturally on progress locally. It is clear, however, that as the new system matures, strategic management above that level needs to be better tailored to a decentralised service. We need a lighter touch, geared to developing the potential of purchasing while respecting local freedoms. It must also uphold and strengthen the national accountability of the health service.

"Regional health authorities have served us well for nearly 20 years. I pay tribute to their chairmen, general managers and staff who have led the health service through challenging times. The old hands-on style of the regions is, however, no longer appropriate. I therefore propose to abolish them. I will bring forward legislation to this effect as soon as parliamentary time permits.

"In a national service, accountable through the Secretary of State to Parliament, a degree of strategic overview is required. For this reason, I also propose to reform the NHS management executive so that it can more effectively and efficiently discharge those functions which must remain the responsibility of central management.

"The NHSME will remain within the Department of Health but will take on a clearer identity as the headquarters of the National Health Service. It will be accountable, through its chief executive, to the Secretary of State for delivering against clearly defined targets and priorities. It will have precise responsibilities for strategic management and a straightforward structure to ensure cohesion and clarity of purpose. Central management will continue to work with professionals to ensure that high quality clinically and cost-effective practice is identified and systematically implemented and that new health problems are tackled in a coherent way.

"The National Health Service is the largest organisation in Europe. Its size, complexity and importance demand that central management operates through a regional structure. No institution in the world, private or public, would attempt to run such a scale of operation from a single headquarters.

"I will therefore establish, as an integral part of a streamlined management executive, eight small regional offices. Each will be run by a director accountable to the chief executive. A regional structure will enable the NHS management executive to give more effective support to the development of local policies. These policies will provide high quality health services to the standards set by purchasers and the health service professions and will ensure effective co-operation across service, education and research. The regional offices will also replace the existing outposts and inherit their responsibility for monitoring trusts. We wish to build on the light touch approach which the outposts have successfully developed.

"Like the outposts before them, the regional offices must be compact. I intend to set a limit on the total staff budget of each office, commensurate with their functions. A similar limit will be set for the management executive as a whole. The NHS needs strong management; but we must bear down on administrative costs to maximise spending on patients.

"Health authority and trust chairmen have a key role as local leaders. They will be expected to play a prominent role in the new arrangements. We must also ensure a non-executive link between them and Ministers. The NHS policy board will therefore be restructured to include additional non-executive members, each covering one of the eight new regions. These regional policy board members will provide a channel of communication to and from Ministers. They will be respected local figures able to make a powerful contribution to ensuring that national priorities are delivered in their areas.

"In light of the need for primary legislation, we expect the new arrangements to be fully in place by April 1996. We have plans, however, to make immediate progress towards a slimmer organisation. I propose to reduce the number of RHAs from 14 to eight by next April and to align the boundaries of the remaining regions with those of the management executive's new regional structure. This would facilitate a smooth transition to the new system. Change will be managed to ensure that the effective day-to-day operation of patient services is maintained. Management cost disciplines and targets will be met at each stage.

"Ten years ago this Government introduced general management into the health service. The author of those changes, Sir Roy Griffiths, observed then that it, 'cannot be said too often that the National Health Service is about delivering services to people. It is not about organising systems for their own sake'. That principle, above all, has guided the changes which I have announced today.

"These changes will slim down NHS management. They will make it simpler and sharper. They will clarify its precise roles and responsibilities and ensure that it delivers results measured against explicit targets. They will save money on administration to spend on patients. They will uphold and strengthen accountability. They will continue the process of decentralisation. And they will support the development of high quality, cost-effective health care.

"A better managed health service means better care for patients. These proposals turn the clock forward to more modern and more efficient management, building on the progress of our health reforms. I commend them to the House."

My Lords, that concludes the Statement.

4.43 p.m.

Baroness Jay of Paddington

My Lords, I thank the Minister for repeating the Statement of her right honourable friend, but fear that it may be greeted with an exhausted sigh by many of those who work in or are patients of the NHS. The Statement quotes Sir Roy Griffiths saying that the NHS, is not about organising systems for their own sake", but I suspect that that is how it may be viewed by many of those in the health service community who find themselves struggling with the realities of the problems of day-to-day life in the NHS with its expanding waiting lists and new funding crises.

Despite the Statement's confident opening tone about the present confident state of the market, I am sure that many of us who use the health service (as well as many of those who work in it) would echo the statements by the chairman of the joint conference of the medical colleges who this week called for the Government to give priority to curbing the gross inequalities of care that have been created by the GP fundholder system and not to emphasise new management arrangements.

Frankly, our concerns about the market are concerns about uncertainty and my concerns about the Statement are that they will make that uncertainty worse. For the past two years, the regions have been a stable force in what has been the very difficult process of managing change. Although I would certainly welcome any moves which helped to achieve a lean, efficient management of the health service bureaucracy, I have to say that it is somewhat paradoxical that this Statement now speaks of streamlining the management to make substantial savings in administrative costs when we know that 18,000 new jobs have been created at a cost of about £41 billion as a result of the restructuring and reform of the health service. We need to ask how much the new changes will cost. What will be the real benefits to patients in terms of released funds? How many jobs will be lost in the regions in spite of the 18,000 that have recently been created?

One regional function, which many of us have valued, has been that of controlling the strategy for regional specialties in clinical care, such as neurosurgery and certain aspects of renal care. Those regional responsibilities have achieved a degree of equity in the services in those specialties which I suspect may now go the way of equity in general as a result of GP fundholder practices. Who is going to plan and organise those important specialties which have previously been organised at regional level?

These questions relate not only to the strategy of planning services, but also to the accountability of the health service. I refer not only to its accountability to Parliament but also to the financial scrutiny which we all recognise as being very necessary.

The Statement twice refers to taking "a lighter approach", but I have suspicions about a lighter approach. Although I recognise that the intention is to release the energies that have been described in the Statement, I fear that a "lighter approach" may mean a looser approach. There have already been considerable anxieties in the past two years about financial laxity in the organisation of local health authorities and local trusts. I suspect that, although we may want to see a tighter approach, a "lighter approach" is not a useful line to take.

I am also concerned about the words used to describe the management executive, which is to become the headquarters of the NHS. Reading the words of the Statement—I have tried to look in more detail at the supporting papers which accompany it—it sounds to me as though the NHSME will become a Next Steps agency. If that is so, it is a very significant change in the organisation of the health service and in its political accountability. It is important at this stage that we understand the principles behind that. If the NHS management executive is to become a Next Steps agency, is that a step on the road towards the privatisation which some of us have suspected?

Another area of concern relates to the additional non-executive members of the NHS policy board. Paragraph 26 of the supporting papers indicates that the eight new non-executive members will have significant powers. They will hold meetings with the chairmen of the health authorities and act as advisers to the Secretary of State, including on—and I think that this is significant—the appointment and reappointment of chairmen and non-executive directors in the regions. The Statement states that those people will be "respected local figures", but I must advise the Minister that there is a certain degree of cynicism among some of us about who those "respected local figures" may be. We must bear in mind the fact that 56 per cent. of the new chairs of the third-wave of new trusts have business backgrounds and that, although that may help them to contribute to some of the financial aspects relating to a trust's efficiency, it does not necessarily reflect a concern about the consumer or equity or any political or philosophical adherence to the health service.

The next point is, who in the new eight small regional offices—the emphasis is put strongly on the fact that they will be small—will scrutinise the DHAs and the trusts? Who will be responsible for their financial probity? My noble friend Lord Dean of Beswick has given your Lordships' House many examples of problems in relation to that issue. Again, the concern relates to the phrases, "the lighter touch" and "the small regional office". We need detail. We need tightness, and, as I have said before, the lighter touch may not be the right approach.

I should like to mention also the special case of London. Why is it that in this Statement the Government seem to suggest that the London area should, once again, be divided into two? Was the case for a pan-London region considered? That is a topic which I am aware is controversial but which has had a great deal of support. If it was considered, why was it rejected? Two new regional offices for London do not seem to meet some of the problems of the reorganisation of London health care that we have all discussed.

Although I should like to accept that something that improves the regional and management structures of the health service is to be welcomed—I am especially interested in and glad to see that FHSAs and DHAs may be able to merge, although there is a question about which side of the provider-purchaser split they fall—overall, my suspicion is that in the present circumstances these proposals will make the market more unstable and more uncertain, and that the lighter touch may lead to less accountability.

Earl Russell

My Lords, I thank the Minister for repeating the Statement. She offers us another reorganisation. While I understand that there are general phrases setting out the case for it, I should like to understand slightly better than those phrases permit the underlying reasons for bringing in this reorganisation. I should like to ask the Minister: is your reorganisation really necessary? However strong the case for reorganisations may be, there is truth in the principle that all reorganisation leads to disorganisation. I know that after the first Question today I cannot condemn disorganisation, but for that very reason perhaps I am entitled to say that I regret it. If the House will forgive one word, I had forgotten that there were no Prayers; I was by the ticker-tape. I am extremely sorry.

This is not merely a reorganisation. It appears to be, if I have understood it aright, a booster rocket to reorganisation, in two stages: first, a reduction in the number of RHAs, coming in by regulation, followed by their abolition, as soon as space for the necessary Bill can be found in the Queen's speech. I wonder why that two-stage process has been decided upon, because the two changes in immediate succession will surely make it much harder for the new organisation to bed down than would otherwise be the case. There will be at least a year, I should have thought, of reorganisation, as it were, in camp beds.

We are again told about the need for decentralisation. I must touch briefly, and not for the first time, upon the paradox of imposing decentralisation from the centre. That sounds like the famous maxim of forcing men to be free.

The note of concern for savings is of course constant. One understands the problem, but in the invocation of efficiency that goes all through this document, I am left wondering whether efficiency really works efficiently; whether enough account has been taken of the concept of the true cost which cannot be reduced by competition, and which is limited by the fact that one cannot provide a service for less than it costs to supply it. I wonder whether we are getting near to the time when we must look again at the whole management culture of which this notion of efficiency forms a part.

I have some misgivings also about the introduction of a cap for regional offices. When one reaches a cap one finds occasionally that the lack of the money for some trifling thing may cause vast extra expenses arising from its lack. The inability, for example, to replace a broken photocopier may increase costs unnecessarily. So, one needs to ask again: does saving always save money? I do not believe that the answer to that question is yes.

I noticed of course in this morning's newspapers the comments of Sir Michael Atiyah on behalf of the Royal Society about the effects of this organisation on money previously spent on research through RHAs. That is a point which has been made before. The division between ministries works unfortunately here. It is always necessary to repeat that the NHS is not just an organisation for treating patients; it is also an organisation for medical research and the training of doctors. If those three functions become separated too much, none of them is done properly. I hope that the Minister can reassure me somewhat about the effect of this proposal on research.

I hope that the Minister can reassure me also that some account has been taken of the start-up costs which are inherent in any reorganisation and which are certain while the savings are uncertain. I share the doubts expressed by the noble Baroness, Lady Jay, about the phrase "a lighter approach". It sounds awfully nice, but what exactly does it mean?

There is a strong case here for more clarity about public involvement; when we discuss accountability, for thinking in terms of local accountability; and, when we consider the boundaries of DHAs, for wondering whether it would save a great deal of muddle if they were to coincide with local authority boundaries. Finally, I ask the Minister whether she can ask her right honourable friend to remember the Foreign Secretary's warnings at Blackpool about the danger of leaving our public services in a state of permanent revolution.

Baroness Cumberlege

My Lords, perhaps I may first reassure the noble Earl, Lord Russell, and the noble Baroness, Lady Jay, that this is not another reorganisation. The reforms started at the bottom. Their whole purpose was to devolve power to the local level, to introduce the concept of trust hospitals with local management boards, and GP fund-holders. Health authorities were to purchase health care by assessing local needs and then purchasing the services to meet those needs. That is all now in place. It is working well. But what is happening is that the top of the organisation does not fit in with the bottom.

The noble Baroness will know, as a member of a health authority that is a purchasing authority in central London, that the responsibilities have changed totally. A great deal of the work that those health authorities are doing now, and increasingly so in the future, will be the work that is now being done by RHAs. That is wasteful. That is bureaucratic. It puts into administration more and more money that should be spent on patient care. We want to weed that out. We want a slim organisation that is effective, accountable, and has a direct link between the people who run the hospitals and the community units to the Secretary of State. That is why we need a non-executive in the regional offices to form that link.

This is a lighter touch. I believe that people in the service will welcome that. The last thing that they want is a heavy, bureaucratic organisation that interferes constantly with local decisions. They want to be able to get on with the job. The system that we have designed will enable them to do so.

I agree with the noble Earl, Lord Russell, that we need clear public accountability. The document which accompanies the Statement sets that out very clearly and I commend/it to your Lordships. Managing The New NHS sets out a great deal of the thinking behind the reforms and will answer some of the points made by the noble Baroness, Lady Jay, with regard to the boundaries; that is, whether we should have a London region or two regions of south and north London. However, I shall not go into detail because I know that other noble Lords wish to ask questions. The logic is clear and I recommend the document to your Lordships.

5 p.m.

Lord Boyd-Carpenter

My Lords, can my noble friend indicate the financial consequences of the changes? Can she name a figure for the increase or decrease in public expenditure which is likely to result? I appreciate that it might be difficult, but it is unlikely that any Government will introduce such changes without having an idea of the likely financial outcome, in particular in one of the largest areas of public expenditure.

Baroness Cumberlege

My Lords, I am afraid that I shall disappoint my noble friend to some extent. We have a rough idea but the NHS is a complex organisation employing 1 million people. We are anxious to have their input on the details of the proposals that we have put forward today. Therefore, I cannot give a definite figure as regards the numbers or the money involved. However, I can reassure my noble friend that we are determined that the slimming down of the bureaucracy in the National Health Service will save money, which will go directly into patient care.

Lord Molloy

My Lords, I thank the Minister for repeating the Statement. Will she take full account of the extremely valid points made by my noble friend Lady Jay? Parliament, and in particular this House, can give excellent service; and I refer to the Statement and the valid points made by my noble friend.

I have been converted to the fact that the NHS should be examined a great deal more. That will be good provided that the reforms are designed to give better patient care. I support that because a large organisation such as the NHS needs constant examination by Parliament. I also believe that we must never forget that the NHS is cast in the noblest mould of any measure that has ever come before our Parliament. It is the pride of our nation and it is the envy of and an example to the rest of mankind.

Baroness Cumberlege

My Lords, I agree with the noble Lord that we need strong accountability. The National Health Service is now subject to independent audit and is further scrutinised by the Audit Commission. We believe that our proposals will not only streamline the service but strengthen accountability.

Lord Carr of Hadley

My Lords, perhaps I may strike a different note. Does my noble friend realise the great satisfaction which the changes she has announced will give to many people inside and outside Parliament who are deeply anxious about improving the standards of care, the value for money and the service to patients which we can obtain from the NHS? All experience shows that when in a large organisation one can remove a whole tier of administration and unite the different parts—as the Government have by bringing together the family health services and the district health authorities —immense benefits flow in obtaining better value for money by producing savings in expenditure or, as I hope, more treatment of the right kind out of the total expenditure on the NHS. Today's Statement marks the beginning of an important step forward.

Baroness Cumberlege

My Lords, I thank my noble friend for his comments. I know that his anxiety has existed for a long time. I believe that the proposals will be warmly welcomed by the majority of people working in the NHS. They certainly should be welcomed by those who use the service because, as my noble friend said, they will mean even more patient care.

Lord Stoddart of Swindon

My Lords, is the Minister aware that many Members on this side of the House are puzzled by her denial of the fact that this is a reorganisation? The management structure is to be reorganised and the number of regional health authorities reduced to eight and eventually abandoned. If that is not a reorganisation I do not know what is. Will the Minister explain that?

Is she further aware that I am surprised that she was unable to say how much money will be saved and how many staff will be made redundant as a result of the reorganisation? I wish to press the Minister on that. I and other noble Lords cannot believe that the Government will undertake reorganisation without knowing the financial effects and the effects on staff. If the Minister cannot give exact figures can she give us some idea?

Finally, can we be assured that the local people whom the Minister will consult about local needs will be chosen from a wide spectrum of the population and not merely from her friends and those of her noble friends in the business and other communities who are members of the Tory Party, with little experience of what is needed in their areas? Can we be assured that the consultation will be wide and that all kinds of people will have an opportunity to give Her Majesty's Government good advice, which they badly need at the moment?

Baroness Cumberlege

My Lords, I reiterate that this is not a reorganisation; it is evolution. The proposals put into place the final piece of the whole reforms. We have established trust hospitals; indeed, by next year the vast majority of hospitals and community units will have become trusts. The legislation will be passed if that is the will of Parliament. We know that family health service authorities, district health authorities and the populations that they serve, advised by community health councils and other organisations, want that change. GP fundholders are becoming established and their numbers are gathering momentum. That is all happening and that is what was intended. We must now look to the top of the organisation and ensure that it fits in with the rest of our reforms. That involves streamlining, slimming down and creating a more effective organisation at the top. I believe that that is welcomed by the majority of people.

As regards non-executive members, yes, we take wide soundings. I have recently completed an analysis of the number of people who help the National Health Service in the form of chairmen and non-executive members. Noble Lords opposite will be surprised to note the number of people who are involved in that way and who are not paid-up members of the Tory Party. Indeed, we have a prime example sitting on the Opposition Front Bench.

Baroness Faithfull

My Lords, will the cutting down of the bureaucratic machine, which we all welcome, bring closer together the doctors, the nurses and the administration? As a result of the heavy bureaucratic structure, the doctors and nurses have not been closely in touch with the administration. Will not the reforms make it possible for them to be in touch?

Baroness Cumberlege

My Lords, my noble friend is right. The strength of the National Health Service depends a great deal on team work. The reforms have sought to bring doctors, nurses and managers closer together. In nearly all hospitals we have seen the establishment of clinical directors. Those directors are doctors and nurses who are working closely with managers. The freedoms which the new proposals will bring will enable that to take place in a more effective way.

Lord Howell

My Lords, is the Minister aware that the claims in the first part of the Statement are mind boggling? Moreover, to suggest that the National Health Service in its present form now has the support of the whole nation is a statement of complacency the likes of which I have never heard. It is all the more astonishing because it was made on the day when the Secretary of State has told us that she has requested Marks & Spencer to open its shop before nine o'clock because she has been harassed by normal shoppers in the store about the state of the health service for which she is responsible.

Noble Lords


Lord Howell

My Lords, it is a question. I would inform the Government Chief Whip on the other side that I intend to continue with my question.

Is the Minister also aware that this very day consultants and doctors representing every hospital and the public in Birmingham have issued a statement about the total disarray of the hospital services in that city? They have done so as a result of the concept of purchasers and providers which seems, these days, to supplant the notion of patients in the health service.

Finally, I turn to the very important point of the democratic control of the health service. To whom are we to depute now when we wish to take up matters of great concern? Who will make such overall judgments, as my noble friend on the Front Bench asked, as to which hospitals will stay open and which will close? It sounds as though the work of those non-executive directors is a very executive role indeed.

I asked to see the chairman of the regional health authority in Birmingham. I went to the National Health Service executive and was referred to a general manager. I complained on the grounds that Members of Parliament and Peers should not be sent to see functionaries; they should be sent to see people who are responsible for the decisions. Can the Minister tell us who will take such decisions and who can we depute to, or write to, in respect of them?

Baroness Cumberlege

My Lords, perhaps I may deal with the noble Lord's first question concerning Birmingham. Clearly, whenever you bring in changes there are people who resist them and who find them hard to accommodate. However, you only have to look at the progress made in the National Health Service in the past two or three years. We are treating more patients than ever before, our waiting times are decreasing remarkably and we are spending money better. However, we believe that there is still room for improvement and that that will come from a streamlined, clearer accountability which will be introduced through the measures that we are proposing today.

With regard to local issues, when noble Lords or Members of another place wish to find out information about their health services, the people to consult are the health authorities; that is, the purchasers. They are the people who make the decisions as to what services are to be provided and how they are to be acquired. However, if it comes to the running of individual hospitals or units which will become community trusts in the future, then it is up to those who are concerned to consult the chairmen of those boards and non-executive directors. The lines of accountability are very clear. We now have more people involved in local hospitals than ever before. They are people who come from different walks of life and who bring in different skills which are clearly benefiting the services that are being provided.

Baroness Eccles of Moulton

My Lords, I should also like to thank my noble friend the Minister for repeating the Statement and to say how much I welcome it. Does my noble friend agree that the proposals for reshaping the regional tier will result in district health authorities having greater scope for developing plans that are finely tuned to the varying needs of the communities that they serve? As the reforms have removed the responsibility of directly managed units from health authorities, they can now concentrate on looking at the real health needs of the population as never before in the life of the National Health Service.

Does my noble friend also agree that the plans to devolve greater responsibility on health authorities for local policy and strategy will make it easier for them to work more closely with local authorities and the independent sector, thus avoiding unnecessary divisions and reducing the risk of gaps, duplication and waste? I should also like to say that I warmly support the proposal for combining DHAs and FHSAs into one authority. As has been said, considerable progress has been made throughout the country towards common boundaries among DHAs, FHSAs and local authorities; indeed, that has happened in many places.

In Ealing, Hammersmith and Hounslow, the DHA has a common boundary with the FHSA and three local authorities. We have already formed a commissioning agency with the FHSA. As our strategies and plans integrate, it is clear that, operating as two separate statutory authorities, we have much duplication and an increasingly artificial division of our responsibilities. Can my noble friend say what can be done to accomplish the bringing together of the authorities with all speed? Once the decision has been announced, as it has today, the sooner the legislation is in place to allow us to operate as one authority the better.

Baroness Cumberlege

My Lords, I thank my noble friend for her comments. As the chairman of one of the district health authorities, she obviously has a very clear vision of how she sees the future. We shall encourage district health authorities and family health service authorities to do just the things that are happening in parts of London by joining together as joint commissioners. We hope that that movement will gain pace and we expect to pass the legislation in April 1996. That is quite a long time to wait. However, it is an evolutionary process and we believe that many people will take the necessary steps so that, if your Lordships decide to pass the legislation, they will be ready to implement it.

Lord Rea

My Lords, I should like to contest a remark made by the Minister in reply to my noble friend. She said that waiting lists were going down. That is not the case in Camden and Islington (my own area) where they have increased considerably over the past year. While discussing the question of London's health service, there is a matter that the Minister has not properly explained. She referred to the accompanying booklet on why London will not have a unified regional health authority. I have read the paragraphs concerned and I am not convinced. I wonder whether the Minister can expand further on the matter? This is a good opportunity to put the special needs of London together under one regional authority.

I should also like to ask the Minister about the proposed merger of FHSAs and DHAs. Up until now, FHSAs have mainly acted in a provider role, looking after the provision of primary health care services. Moreover, through their contracted practitioners, they also have an indirect purchasing role. That is especially so now through fund-holding practices, whether one likes it or not. However, they are in fact a relic of the type of authority which was both purchaser and provider. Is it the intention that the provider element will be part of the merged DHA/FHSA? Further, will GPs not lose the special relationship that they now have with FHSAs as providers of primary health care? The help that they receive from FHSAs is, in the main, greatly appreciated. I can predict with certainty that there will be much discussion on the issue in the months ahead.

Baroness Cumberlege

My Lords, I should like to reiterate that, nationally, waiting times are coming down and that in no part of the country are people waiting for over two years now for an operation. That was not the case three years ago. London is a very complex problem. As noble Lords will know, there are many decisions to be made regarding the services in London over the next few months. It was the view of Ministers that we did not want to go for a total London health authority. When one looks at how resources have been allocated in the past, London sucked in a disproportionate amount of resources in order to serve its population. We know that where reallocations have taken place and where redistribution has been successful, it has been because the other areas associated with inner and outer London have ensured that they get a fair share of the money that is available.

If one looks at the coastal areas—South West Thames is a region I know well—regions such as Chichester, Worthing and mid-Downs kept asking us what we intended to do about the over-resourcing of London. That enabled us to ensure that some of those resources were re-allocated. There are some complex problems in London. We believe they are best dealt with by looking to the north of the river for a north London authority and south of the river for a south London authority.

The Earl of Onslow

My Lords, is it within order—

The Lord Privy Seal (Lord Wakeham)

My Lords, we have taken up the 20 minutes available. The Companion to the Standing Orders states that we should now move on to other business.