HL Deb 05 April 1995 vol 563 cc199-211

4.7 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 changes to the health service 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:

"The decisions I announced yesterday follow four separate statutory consultation exercises about hospital changes in south and east London and around Barnet and Edgware. In each case, the decisions measure up against the Government's key objectives for improving the health service in London: to strengthen specialist services by concentrating them in centres of excellence; to preserve and enhance medical teaching and research in the capital; to provide more modem acute hospital services closer to the major centres of population; and to release money to increase investment in family doctor and community health services which are badly needed in parts of the capital.

"Those key elements of the Government's strategy will be familiar to the House. I set them out in a Statement at the time of the publication of the Tomlinson Report and again when I announced my response. They have been frequently debated. I said on those occasions and I say again: the objectives of this strategy enjoy widespread support within the clinical and academic worlds and from independent commentators such as the King's Fund. The need for change in london is widely recognised and widely recognised as long overdue.

"I hear and understand the concerns which have been expressed. We considered very carefully the points made during the consultations including those made by right honourable and honourable Members in their meetings with me and the Minister. I was, in particular, struck by the points made about the pace of change. The extended time-scale of some of the announcements yesterday respond to those points. Let me make it absolutely clear: no accident and emergency facility, or indeed any other, will close until Ministers are satisfied that the alternative facilities are not only available but capable of providing an improved service to patients.

"My right honourable friend asks specifically about the financial implications. The changes announced yesterday will be backed by £400 million of capital investment—that on top of the £210 million that we are already spending on improved primary care. This is substantial investment in a modern health service.

"That money will buy, among other things, a new NHS hospital for Greenwich, and an upgraded hospital in Barnet, complete with a state of the art accident and emergency department and a world-beating centre for neurosciences and neurosurgery at King's. It will support the changes at the Royal Hospitals Trust and Guy's and St. Thomas' which will develop them as centres of supreme excellence in treatment, teaching and research. In addition we are investing substantially in other hospitals such as the Homerton, Lewisham, King's and the Royal Free.

"Aside from the direct clinical benefits, we expect these changes to lead to substantial revenue savings which I estimate will be of the order of £75 million every year once the changes are complete. This is money which can and will be invested elsewhere in the health service, both in community health services in London's areas of greatest need and outside the capital.

"I say to the House that, at the moment, rather than getting £75 million out we are putting in £28 million a year, supporting the duplication and fragmentation of services around the four areas covered by my announcement. That must be a good exchange by anyone's standards. As for St. Bartholomew's and the Royal London, the capital investment will total nearly £240 million. It is expected to deliver revenue savings of some £30 million a year. This compares to the current subsidy going into the trust of £8 million a year.

"I say this, however, in conclusion to my right honourable friend. The changes which I announced yesterday, and which carry forward our strategy, are not primarily about finance. They are about improving the quality of care. They are about better specialist services where medical expertise is enhanced by bringing clinicians together to benefit from each other's ideas. They are about better teaching and research—linking world-class hospitals to multi-faculty colleges. They are about equipping modern hospitals to respond more flexibly to the pressures they face and to harness the awesome advances in medical technology. And they are about providing more health care where Londoners most badly need it—in their communities, their doctors' surgeries, and the streets where they live.

"It is on this basis that I took these decisions. Change is not easy, but it would be harder for London if we do not change. These changes will build towards a first-class health service for London, fit for the 21st century, and they deserve the support of this House".

My Lords, that concludes the Statement.

4.12 p.m.

Baroness Jay of Paddington

My Lords, I thank the Minister for repeating her right honourable friend's Statement. I am particularly pleased that she has done so because it gives your Lordships what is a rare chance to question the Government about important decisions in the NHS at the time they are made. It is somewhat ironic that the Statement has been forced out of the Government in another place on a day when yet another major NHS document has been published and circulated. It is particularly ironic that it is about openness in the NHS. However, today we are here to discuss the Statement which has been repeated by the Minister.

The Minister spoke in the context of the Tomlinson Report. Have the Government considered those reports which have been published and the inquiries which have been conducted since the Tomlinson Report and which give a rather different picture of the needs of London? I refer particularly to that which was conducted by the chief executives of the inner London health authorities, the one conducted by Professor Jarman, who considered whether London was underbedded or overbedded, and indeed the updated King's Fund report on the situation in London which does not entirely support the view of its earlier report, although it was of course that report which stated that money for primary care should come up front before any other changes were made. I should like to ask the Minister whether the new changes pay due attention to the authoritative reports published since Professor Tomlinson made his suggestions.

As regards specific matters, the Statement says that no accident and emergency facility will close until Ministers are satisfied that alternative facilities are available and capable of providing improved services. Will the Minister comment on the situation at Guy's Hospital, one of those mentioned in the Statement as being subject to change, where I understand the A&E department, which has just had £1 million spent on it, is likely to be closed by 1999 without any suggestion being made for its further use? Will the Minister comment on the point about the need for investment in primary care before acute sector beds are closed? In the past Ministers have spoken about the inappropriate use—I think it has always been a rather inappropriate use of words —of A&E departments by Londoners because of the lack of primary care. However, as we all know, the lack of primary care is partly because it has not received substantial investment and there was no substantial improvement in services before these radical decisions were taken.

How much is known about the shift of resources between acute care and primary care which is supposed to lead to redistribution of services? I suspect that the situation in London is probably more like that which I know to exist in the health authority of which I am a member where the number of people registered with general practitioners has fallen in the past few years. So the ability to use primary care services has obviously fallen at the same time and A&E continues to be used "inappropriately".

Have the Government also considered the work done recently on the problems of homelessness in London and the work of the London task force on mental illness which again shows a particularly acute need for special services in London? The Minister will know that, as regards mental health beds, there have been several reports of bed occupancy being at 120 or 130 per cent. How can that possibly tie in with the closure of beds suggested in this report? How many beds will be closed as a result of the changes? How do we know precisely in what way need will be met by these, I am afraid, rather mythical improvements in primary care'? Is the money which is to be spent on more' capital investment in this field new money or—as I mentioned before—is it the result of a possible shift in resources which we do not know enough about?

In a debate in your Lordships' House last week on an amendment to the Health Authorities Bill proposed by the noble Baroness, Lady Robson, a question was raised with regard to the need for a strategic health authority for London. The noble Baroness, Lady Miller of Hendon, who replied for the Government, said that the need for a strategic authority for London was probably redundant because a lot of the work that was needed was already being done by the London Implementation Group. She listed the particular concerns that the LIG had been looking at which included concentrating, developing and enhancing specialist healthcare services; taking action for the benefit of teaching and research; and indeed improving primary and community health services. Somewhat surprisingly, the noble Baroness added that the work of the London Implementation Group is now complete. We know that the London Implementation Group will be disbanded in the very near future.

Can the Minister give any kind of end-of-term account of whether the London Implementation Group has been able to reveal the shift in resources and the improvements in the areas on which it has been concentrating in order to give us much greater confidence about these radical changes to acute services? I remind the Minister that although the Statement refers to the King's Fund as an authoritative source, she will know that the latest suggestion of that fund is that its judgment of the resources needed for London was greatly under-estimated. I ask the Minister to consider that these decisions are being taken in a rushed way without due concern for the long-term changes which need to occur before we can feel confident about the reduction in acute care beds in London. I echo the stance which has been taken on these Benches on many occasions. I believe there must be a moratorium on closures pending a full inquiry into all the health needs of London.

Baroness Seear

My Lords, I, too, wish to thank the noble Baroness for repeating the Statement. I do not wish to be carping but it seems to me a great pity that we should have to interrupt the debate on probation officers, which is an important subject, in order to turn our minds to another important subject. That surely is not the best way to consider matters which are of cardinal importance to a great many people.

I continue my grumbles by saying that this document was handed to me a few minutes ago. I understand that it was only available then. How one is expected to make any intelligent comments when the information arrives at such short notice, I do not know. This discussion surely could have been postponed until we had longer to think about the matter.

So many questions have already been asked by the noble Baroness, who knows a great deal more about the subject than I do, that I want only to emphasise one or two points. In particular, I should very much like to know and have some reassurance about what is meant by the words in the Statement that, no accident and emergency facility...will close until Ministers are satisfied". Does that mean again that once Ministers are satisfied they will tell us what is to happen? Or does it mean that when a further report has been produced we shall be given the information and have an opportunity for a real discussion on the subject? It is not only in this context that we find the Government's understanding of the word "consultation" somewhat confusing, to say the least.

I should also like to ask what is really going to happen. It is tantalising. We are all extremely interested, and those of us who have been patients in some of the hospitals mentioned are particularly interested, to know what exactly will happen in respect of the amalgamation of Guy's and St. Thomas'. Or has that been abandoned? Everyone will be very interested to know. Whenever I go to those hospitals I find that people are still confused. The staff are demoralised by the fact that nobody really seems to know what will happen. Is this not an opportunity to give people a clearer view of what is to happen?

Similarly, the Statement indicates that at St. Bartholomew's and the Royal London capital investment will total nearly £240 million. If the hospital is supposed to be running down or is ultimately to be closed, what is that £240 million to be spent on? Or will all the money go to the Royal London? Can the noble Baroness tell us?

Of course I accept, as a Londoner, that in the past certain parts of London have undoubtedly suffered from the inadequacy of primary health care. Nobody will deny that primary health care is the foundation stone of any health service. For example, those of us with experience of trying to look after seriously ill people at home who have wanted help in the night from the medical service have found it almost impossible to obtain the assistance one would hope would be available. If the changes mean that that situation does not arise in the future, most of us will be very grateful. Is that what is intended?

I am afraid that having read the Statement I am still very much in the dark as to what is to happen.

Baroness Cumberlege

My Lords, perhaps I may address the comment of the noble Baroness, Lady Jay, that this is a rare opportunity to debate the London questions. I remember very clearly having a major debate in this House on the health service in London and its future. Indeed, I remember on that occasion the noble Baroness making the very profound remark that 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. Therefore, we had some modest support from the noble Baroness at that time for major changes in London.

Baroness Jay of Paddington

My Lords, I am sorry to interrupt the noble Baroness. That is a rather strange way to respond to what I said. I did not say that we had not had opportunities to discuss the situation in London. I said that it was useful to be able to look at a health service decision on the day it was taken. Of course I agree with what I said about Professor Tomlinson's report. However, I began my remarks by saying that many other people have reported since Professor Tomlinson. Have the Government taken any notice of those other reports whose conclusions have been somewhat different in making these decisions?

Baroness Cumberlege

My Lords, of course we have listened to other people. Indeed, we have listened to the King's Fund. On 9th March this year Robert Maxwell, secretary of the King's Fund, said: Our own position is that the strategic objectives of current policies are largely correct but that great care is needed with the handling, sequence and pacing of changes". As I said in the Statement, we have taken account of those comments, and others, in that we have ensured that in relation to Guy's and Bart's we have allowed more time to bring about these major changes so that they occur at a slower pace.

We have also listened to many other people in addition to Professor Jarman. The noble Baroness will remember that Professor Jarman's concerns were not so much with the loss of acute beds as with the fact that primary care in London was very poor. That is a conclusion with which your Lordships have agreed every time we have discussed the subject. He was also concerned that there were not enough long-term, continuing beds. The health authority of Lambeth, Southwark and Lewisham has already received 650 applications for nursing home beds. Those are to be registered. The London borough of Lambeth is investing in 150 beds for long-term care. Therefore, we are trying to meet the problems that Professor Jarman outlined and are investing quite heavily at Guy's in mental health beds.

We have also listened very carefully to the independent specialty reviews that we ourselves commissioned. Dr. Chris Paine, president of the Royal College of Radiologists, said that he felt that there was a need for fewer, larger specialist centres, most closely linked to general hospitals, and that that would lead to a stronger service and research base than we have now.

In the cardiac review Professor Geoffrey Smith, president of the Society of Cardiothoracic Surgeons, when studying care in London, said that none of London's existing 14 centres provided adult tertiary cardiac services which met the criteria laid down in all respects, and many fell well short.

Service, research and development and teaching considerations all point to the concentration of resources and expertise in fewer, larger centres.

I could go on and mention Mr. Rab Hide, chairman of the neurosciences review, and Professor Sir Norman Browse, president of the Royal College of Surgeons. They were at one in saying that there was a need for services in London to be reorganised to meet the needs of the 21st century.

We are investing very heavily in primary care. Your Lordships have always felt that that was the way forward for London. Over the next three years we shall invest £210 million in over 1,000 primary care projects. Some of those are nearing completion and others are under way. A huge amount of investment is taking place.

The London Implementation Group was always a time-expired body, as recommended by the King's Fund, when the commission produced its report. The major decisions have now been taken. The implementation of those decisions is up to the two regional health authorities and the district health authorities. We rely on our normal management processes and systems in order to do that.

The noble Baroness, Lady Seear, asked about accident and emergency units and consultation. Whenever we make major changes we have to consult. All the proposals before your Lordships in the Statement today have been heavily consulted upon. If there are changes to the accident and emergency departments we shall of course consult further. We have given an undertaking that we will not close any department unless there is alternative provision which is at least as good.

I think that I have covered most of the points raised. If I have missed some I am very willing to come back to them.

4.28 p.m.

Lord Boyd-Carpenter

My Lords, can my noble friend add a little to what she said about the closure of beds? I understood her to say that closure would not take place until alternative facilities had been provided on an adequate scale. Can she say what is the total number of beds it is intended ultimately to close under these changes?

Secondly, can my noble friend say whether allowance is made in these changes for the fact that the high standard of medical care in London attracts patients from all over the world, particularly from the Middle East? Has due allowance been made for the inflow of patients into London due to the high standards of care which it is appreciated throughout the world are to be found in London?

Baroness Cumberlege

My Lords, yes. As we see medical care change we see increasingly more patients treated on a day case basis. At one time operations for cataracts required 10 days in hospital. As noble Lords are aware, those can now be done on a day case basis.

Regardless of what happened, we would see reductions in beds. We seek to ensure that it is a controlled reduction, that it makes sense, and that there is sufficient investment not only in day treatments but also in community developments to make up the loss.

To be specific, with regard to the Bart's closure, we expect a loss of something like 188 beds. But with regard to the Royal London Hospital and Homerton, we expect more patients to be treated than are at present being treated within the three hospitals. With regard to Guy's and St. Thomas', we expect something like a loss of 263 beds. However, the time has come when we have to consider healthcare not in terms of loss of beds but of patients treated and the quality of care given. We know that many would rather be treated locally by their own GPs if only the primary care were good enough.

Lord Marsh

My Lords, I speak as one who would certainly not agree with the Minister's view that the changes in some areas are moving at a fast pace. Does she accept that the Statement is of positive help? One hopes that it will enable those organisations which were reluctantly forced to block large payments in relation to Guy's rebuilding—in the case of my own organisation the amount was more than £9 million; and there were other large sums involved—to reconsider their position with a view to releasing those moneys and therefore ending at least some of the destructive uncertainty which surrounds the reorganisation at present.

Does the Minister also accept that there is an urgent need for the Government to announce a firm, clear policy and to stick to it? All the issues in this controversial area have been well argued and are well known to anyone interested in the subject. The possibility of the Minister and the Government finding total agreement with their proposals is limited, to say the least. The key factor now is to get on with the policy and to stick to it.

Baroness Cumberlege

My Lords, I agree very much with the noble Lord. Perhaps I may pay tribute to the work that he has done through the trustees chairing that body at Guy's Hospital.

The noble Lord is completely right. Uncertainty is very damaging not only to institutions but also to the staff who work within them and others who are in academic or research positions. I agree with the noble Lord that the case has been well argued, well reasoned and well debated. Indeed, we have had 20 reports in the past 80 years all saying roughly the same. I have to say that there has been no Secretary of State more courageous than the present Secretary of State. She has grasped the nettle and is determined to continue. We are firm. We are clear. We have a policy which we believe will improve the services for the people of London.

Lord Jenkin of Roding

My Lords, does my noble friend accept that many noble Lords on this side of the Chamber totally support my noble friend's remarks concerning her right honourable friend the Secretary of State who has shown enormous courage and constancy in seeing through what we always recognised would be a difficult and in some cases a stormy process? However, is not my noble friend absolutely right to concentrate on the need to improve the primary care and community care services? Was it not astonishing to hear the noble Baroness, Lady Jay of Paddington, refer to mythical investment in primary care? I wrote down her words.

There are a thousand projects; my area of east London—it includes Walthamstow and Waltham Forest—has the highest concentration of single-handed practitioners in the entire country. Is my noble friend aware that many projects are financed through the London Implementation Group programme—

Baroness Jay of Paddington

Perhaps I may—

Lord Jenkin of Roding

The noble Baroness must learn to sit and take criticism and not to jump up every time someone criticises her.

Lord Richard

The noble Lord is supposed to ask a question.

Lord Jenkin of Roding

I was asking this question. Is my noble friend aware that in that area of London a great many projects are going ahead which will realise the ambition of a primary healthcare-led service? Is such a service not at the heart of the whole reform? It is what doctors and other professionals in the health service, including the chief executives of the inner London health authorities to which the noble Baroness, Lady Jay, referred, have been demanding for years. My right honourable friend the Secretary of State is now delivering that service. Is it not right that she should be allowed to provide it?

Baroness Jay of Paddington

My Lords, I apologise for interrupting the noble Lord. I had thought that he was sitting down; I misunderstood. As I am sure he knows, I am perfectly capable of taking criticism. I wish to ask a supplementary question. The Minister did not respond to my original question. If there has been such successful investment in primary care where is the end-of-term report of the LIG?

Baroness Cumberlege

My Lords, it is on the ground. The noble Baroness has only to come with me to visit some of the remarkable schemes that are now taking place. I do not refer to all the schemes because it takes time to appoint people and to build new health centres, and so on. But we are seeing a tremendous improvement, as my noble friend said.

There certainly is room for improvement. We know that in inner London there are 25 per cent. fewer practice nurses helping GPs than there are practices; that 80 per cent. of GPs nationally offer minor surgery but in inner London the figure is only 46 per cent., and that that accounts for some of the accident and emergency overload that we have experienced; that almost twice as many GPs work alone in London compared with the national average; and that in London twice the national average of GPs are over 65 years old.

Noble Lords will know that the noble Lord, Lord Rea, is a GP working in London. When we have had debates in this House, he has often spoken of primary care. Indeed, he asked me for the list of the 1,000 projects. I have given him that list. If the noble Baroness would like to accompany me, we shall go round London and see what is happening on the ground.

Lord Butterfield

My Lords, perhaps I may slightly shift the thrust of the questions and observations towards education and research. Can the noble Baroness give a reassurance—I know that it will be widely appreciated among the academic and research communities—that there is full support for the key objectives that she mentioned? The shift in the pace of change will be widely appreciated. It will give people the opportunity to think through their research applications and plans.

However, I am sure that the noble Baroness knows that there is a widespread hope in Guy's that a suitable division of specialist services and specialist beds between Guy's and St. Thomas' can be worked out. It is greatly hoped that there will be opportunities to improve the training of the undergraduates in primary care activities. It is hoped that such educational development, and a service bridging the gaps while primary care is built up, can be established on the Guy's site. It is very much hoped that the shift towards home treatment and outpatient services can be developed at London Bridge because of the wonderful transport connections. Indeed, some of us cast our eyes over to that remarkable polyclinic which is to be found in Leiden. The circumstance is similar to the relationship between the new hospital being constructed at Guy's and London Bridge Station. It allows people from a wide area to come to a centre where the research people are in a strong position to give what so many patients demand. Indeed they demand it in primary care. It is real reassurance about the diagnosis that they receive. That reassurance comes from a research, knowledge-orientated, teaching hospital environment.

Perhaps the noble Baroness will give reassurances that research in surgical, dental and psychiatric subjects will be cosseted and will make its contribution to the London scene. It is such a strong scene that we all realise that we can play only a part in it. I should be most grateful if the noble Baroness will give me some reassurances to take back to my young men and women.

Baroness Cumberlege

My Lords, I know that the noble Lord, Lord Butterfield, has a long-standing interest in medical education and research and has worked tirelessly to improve it. I am sure that he will be reassured to know that today the provost of University College London, Dr. Derek Roberts, has announced that University College London has been given £11.5 million by the Wellcome Trust and £14.5 by the Higher Education Funding Council for England to fund a new teaching centre for medical students and a major new medical research centre at University College Hospital.

I know that the noble Lord's particular interest is in Guy's Hospital. I hope that I reassure him that our vision for the future is for Guy's to be the centre of excellence in terms of teaching and research. We have much support from the Vice-Chancellor of the University of London. We believe that the linking now of medical schools with multi-faculty colleges will strengthen them, as indeed they have been strengthened in other parts of the country, for example, in Oxford.

We are concerned that our teaching and research should not fall behind. We want to be a world leader and a world beater. We want to attract students from all over the world to benefit from our medical education, which we believe is the best but which has to struggle very hard to maintain that position.

Lord Stoddart of Swindon

My Lords, the noble Baroness says that there had been a lot of consultation. Was there consultation between the Secretary of State and her right honourable friend Peter Brooke? He does not seem to believe that there was proper consultation with somebody who had a real interest in that area and in Bart's in particular. Has there been proper consultation with all the staff of St. Bartholomew's? My information is that there has not been proper consultation and that they will by no means be satisfied with the Statement which the noble Baroness repeated today.

Can the Minister also explain why the Secretary of State for Wales seems to take a completely different line on reorganisation from that taken by the Secretary of State for Health? Apparently, he believes that many of the older buildings are perfectly suited to modem methods and that much of the reorganisation is for administrative and financial convenience. I wonder whether the noble Baroness would comment on that.

Finally, can she say whether the £210 million for primary care to which she referred is new money or is it to be transferred from elsewhere to somebody else's detriment?

Baroness Cumberlege

My Lords, with regard to consultation in that part of London, 5,000 copies of the consultation document were printed and around 2,500 were issued immediately to all interested parties, which would have included staff. A further 2,000 copies were issued in response to requests. At the same time 40,000 copies of a short leaflet were printed and large numbers were issued to relevant outlets, with a further 14,500 copies issued in response to requests. The leaflet also included a message in eight languages inviting the reader to telephone the language line service, which provided a telephone interpreter service in those languages. Three public meetings were held, one in each locality. They were arranged by the authority and senior representatives of the authority. Those people attended 15 other meetings arranged by the community health councils, professional groups, social services departments, and so on.

So the noble Lord will be aware that there was a very great deal of consultation among staff and among the general public. Indeed, to my certain knowledge, the Secretary of State has met with her colleague on several occasions, not least in the past week or so, when I believe she has met him three times.

With regard to the Secretary of State for Wales, perhaps the noble Lord will read very carefully what he said. He said that he felt that services in the future should be clinically driven. We believe in that. We are carrying out these developments primarily to improve the services in London: the health service, the academic teaching and research and development. Those are clinically driven services.

With regard to the primary care money, the total investment is £400 million overall in London, but the £210 million has been allocated through the normal budget round. It is new money. It came, as it normally does, through the distribution mechanism from the Treasury.

Perhaps I may also say that the noble Lord will be aware of the enormous amount of money that the National Health Service received this year—£1.3 billion extra funds.

Lord Annan

My Lords, I wonder whether the Minister was as amazed as I was when the noble Baroness, Lady Jay—I sympathise with some of her worries—asked for yet another full inquiry to be made at this time and said that we were coming to rushed decisions. Was the Minister not absolutely dumbfounded—perhaps dumbfounded is the wrong word—when the noble Lord said that there had been no consultation with Bart's?

For 30 years we have had consultations with Bart's about getting into bed with the Royal London. Would they move? No. Every attempt to have any kind of discussions even of the problem have been completely and absolutely refused by Bart's. That is in marked contrast to what has happened in other parts of London. Does the Minister agree that in north London, for example, a marriage was arranged with University College and the Middlesex and that that has now become a very happy partnership? I believe that the Royal Free, which again for years refused to talk, is now beginning to move and become part of that partnership. The same is happening in west London.

I appreciate, as I am sure does the noble Baroness, the difficulties which face Guy's. But surely that is bound up with obtaining funds for King's pre-clinical school perhaps to move ultimately to the site by London Bridge and make one of the four new multi-faculty centres.

Baroness Cumberlege

My Lords, I should very much like to thank the noble Lord, Lord Annan, who has for a very long time taken an interest in the London hospitals. As a former Vice-Chancellor of London University, clearly he has a very keen interest in them. He is quite right; we are now seeing a huge sea change throughout London. There is a different attitude among many of the London hospitals, which recognise that in world terms they have to get together, that there has to be a critical mass and that they have to be linked in with multi-faculty colleges if they are to survive and indeed lead the world. There is a change, and change is always difficult.

Clearly, St. Bartholomew's Hospital is finding the situation more difficult than most. However, I believe that these changes are the right way forward. The new campus at Guy's will not only be a centre for education in medical terms. We also propose to take there the school of nursing. It will be very closely linked with other basic sciences within the university. I believe that it will prove to be a very new form of centre for teaching. It is an exciting development. I know that others involved share that view.