HC Deb 14 June 2000 vol 351 cc226-48WH 10.55 am
Dr. Jenny Tongs (Richmond Park)

This debate was requested by some Liberal Democrats from south-west London; it was not initiated solely by me. We hope that the Government will treat it as part of their consultation exercise. I cannot mention everything, but I want to raise one or two matters in the context of the future of the national health service and the next tranche of money that the Government will allocate to it. I do not speak as a Liberal Democrat spokesperson; this is a Back-Bench debate, so for its purposes I am a Back-Bencher, expressing my Back-Bench views.

The Prime Minister often says that the NHS must get used to change. However, at present, the health service is definitely sick and one of the causes of its sickness is change—unfortunately. Although I accept that much change is needed this time—this year—the Government must get it right. We cannot go on reorganising the health service, because the energy of everyone—managers, doctors and nurses—is going into the process of change and reorganisation, instead of into the improvement of patient care. As someone who has worked in the health service for many years and who has undergone many changes and reorganisations, I plead with the Government to try to get it right this time.

The health of Londoners has always been at issue. I have been practising for long enough to remember when the Black report on the health of Londoners was published. I do not know what happened to that report. It stressed the importance of the link between poverty and deprivation and ill health. It made exactly the same points as eight subsequent reports. I do not know why we have to keep producing reports that say the same thing.

London has some incredible centres of excellence. Some of the best medicine and surgery in the world is practised in this city, but, at the other end of the scale, we have inner-city areas where medical facilities are appalling and where there is squalor, poverty and ill health.

I was considering the health services in the Tottenham area, as a by-election will be held there soon. They are patchy. I compared some of the statistics for Tottenham with those for Richmond, which is in Surrey but is also a part of London. In Tottenham, the infant mortality rate is three times higher, and the rates for tuberculosis are five times higher than those in Richmond.

Long ago, as a medical student, I was taught that a key indicator of poverty and deprivation is TB. It occurs where there is poor housing, poor health and poor nutrition. We have that in areas of London. I obtained the figures for TB from the Library; they clearly show a frightening rise in the number of cases in London over recent years.

I have spoken to people who work in the national health service who have had to contend with, among other things, the recent scandalous shortages of TB vaccine. I must draw the matter to the Minister's attention. It is no excuse to say that the manufacturer does not want to manufacture the vaccine any more because the patents have run out and it is not making enough money from it. Someone must get on with manufacturing that vaccine, so that a generation of children does not grow up unprotected against TB. TB is on the march and it is resistant, and it is an indicator of what needs to be done in this city.

Let us consider the modernisation funds that were recently given by the Government and gratefully received by the health service. I understand that the first tranche was intended for primary care development, but in the London area 90 per cent. of it was used to address the deficits of the trusts; it did not go into primary care at all. The London region had allowed St. Mary's hospital and the Chelsea and Westminster hospital—large, famous teaching hospitals—to run up huge deficits. The new money was used to pay off the debt.

The remaining 10 per cent. of the first tranche was used to pay off the overspend on drugs in primary care. I know that the Government are addressing that problem, so I shall not go into it in detail; I simply ask how will the Government ensure that the second tranche of money, which we are all looking forward to, will be used for patients, not to cover the debt that has built up over years of mismanagement of the health service. In attributing responsibility for that mismanagement, I would cite previous Governments more than the current Government.

General practitioners are very enthusiastic about primary care groups and trusts. After initial reservations, all the GPs in my area whom I talk to now express enthusiasm. Particularly in the London area, we desperately need computerised records, but they must link up with those of hospitals. I understand that my local health authority, the Kingston and Richmond health authority, will run a pilot scheme for computerised patient records. I hope that the hospitals will be as enthusiastic about it as the general practices are, because it seems to me that the consultants and some of the people working in the hospitals are less enthusiastic about the switch to computerised records than the GPs.

Before I leave the subject of GPs, I repeat my plea on behalf of those in the London area who have had to wrestle with the problem of asylum seekers in the past two years. It has been a great problem for them. One of the greatest difficulties has been the lack of translators and language facilities. Everyone knows that there is a telephone line that one can ring to obtain a translation of almost any language, but it is very difficult—as I have found—to conduct a consultation with a patient in a consulting room when a telephone is in the way.

Mr. Philip Hammond (Runnymede and Weybridge)

Does that remark indicate a lack of confidence in NHS Direct, where there is a telephone in the way of the consultation?

Dr. Tonge

No. The patient telephones NHS Direct and receives advice. As a doctor, I have reservations about that service, but I was referring to the language service that doctors can use when they have a patient with whom they cannot communicate. I have had to use it myself. One rings the language service and speaks to someone who can speak Serbo-Croat or whatever language one needs, and then one has to interview the patient via the telephone, which is terribly difficult—almost impossible. I hope that the Government will acknowledge that GPs in the London area have been wrestling with those problems.

Although it is not a feature of London alone, a problem remains in co-ordination between health services and social services. I have worked on both sides of the pale: I have been chair of a social services department and I have worked as a manager in community health. The two sides must be brought together. The Liberal Democrats would like to see them brought together under the auspices of local government. I do not mind any more how they are brought together, but they must be brought together. In the interests of patients, the buck-passing cannot continue.

I shall briefly discuss beds and NHS facilities. Over the past 10 years, there has been a 35 per cent. reduction in acute beds in the health service in the London area. I have failed—someone else in the Chamber might be able to help me—to find the figure for the percentage reduction in mental health beds, but I know that too many have been closed and that even the Government admit that.

The enthusiasm for competition and the internal market led hospital to fight hospital against closures. In my area, two hospitals were competing for supremacy. To show their hospital in a better light than the competitor, managers made extravagant claims and projections about how they would cope with patient flows, where patients would go and how facilities in their hospital would be able to cope—claims that did not materialise.

I plead with the Government: if there are to be any more closures in the London area, for heaven's sake let us have the extra facilities in place before a hospital is closed. In my area, the closure of facilities at Queen Mary's hospital in Roehampton created chaos at Kingston hospital. I pay tribute to the staff and managers at Kingston hospital who dealt with that, but the casualty department was woefully inadequate. Now, thankfully, the money has come through and a new casualty department will be ready at the end of next year, but that should have been in existence before Queen Mary's hospital closed; likewise the beds to replace those in Queen Mary's hospital. What I describe as a portakabin ward had to be put up to accommodate the extra patients. Funding has only just come through to create a proper ward block to look after our patients adequately.

If my hon. Friend the Member for Kingston and Surbiton (Mr. Davey) had been here—I pass on his apologies—he would have told hon. Members that in our area we also urgently need better diagnostic facilities. Patients from a huge area depend on Kingston hospital, and the facilities at Queen Mary's hospital are sadly out of date. For example, we have no magnetic resonance imaging in the area. In the United States, every hospital has an MRI scanner—it is standard diagnostic equipment nowadays. We must have proper facilities. Likewise, for radiotherapy we have old cobalt machines instead of linear accelerators. There is so much to be done.

The bed closures have caused a phenomenon that horrifies me. Bed occupancy rates are often touted. If we visit hospital managers—I do so regularly—we are told that bed occupancy rates are 95 or 96 per cent. My response is that that is a disgrace. It is impossible to run an acute hospital if 95 per cent. of its beds are occupied all the time. The result is that sick people must wait on trolleys and chairs for empty beds. In the mental health sector in London, the bed occupancy rates are 130 per cent. That does not mean that there is one patient at the top of the bed and another at the bottom; it means that while a patient goes out for treatment for a day, another patient occupies their bed while they are away. It is appalling.

High bed occupancy also causes poor hygiene. Recently, I initiated a debate about the rise in methicillin resistant staphylococcus aureus infection and the lack of hygiene in NHS hospitals. High bed occupancy is the cause. There is not enough time even to wash one's hands between patients, to clean down drips caked with blood or to ensure that the ward is tidy.

We cannot continue with such occupancy rates. They cause bad practice and corner cutting, and if there is an influenza epidemic or a disaster—such as a serious crash—they cause mayhem. I have experienced it. We must tackle the problem. We need more empty beds in the national health service, and we need more low-tech beds for the so-called bed blockers—those poor and mainly elderly patients who cannot be sent home and must be kept in hospital while social services and the health service pass the buck between themselves to decide whose responsibility they are.

I urge the Government, before they close any more small hospitals and cottage hospitals, to think very seriously about improving those hospitals in the London area in the context of low-tech beds, GP beds and nursing beds where elderly patients can receive the sort of care that they expected to receive for the rest of their life from the health service.

Other issues that affect London disproportionately are pay and accommodation. I saw a student nurse in my surgery last week. She is a mature student with two children, but her husband walked out on her three years ago, so she is on her own. She had managed to find a house that was just about big enough for herself and her two children and the rent was £10,500 a year. That is a bargain and good going in the Kingston and Richmond area, so she is not complaining about that. However, her bursary—it takes into account the fact that she has two small children—to be a student nurse at Kingston university and at St. George's hospital in Tooting is £8,500. Because she is a student nurse, she cannot claim income support and, because she is not on income support, she cannot receive housing benefit.

There is no way that my constituent could manage unless she did care assistant work at night. She thought she might be able to claim the working families tax credit if she carried out her studies during the day, picked up her children and worked at night. However, she then faced the problem of finding someone to look after her children at night, and that costs money. Will the Government please examine this problem, which does not affect only student nurses? I have been lobbied by other nurses. One of them said, "I'm really lucky that I have a council house, but my pay and conditions are so awful. I am so busy, tired and stressed that I think that I am going to have to leave nursing."

The price of accommodation is a big problem in London. I do not know whether it can be addressed through London weighting. It affects not only nurses but pathology laboratory technicians. We have all heard about the cytology technicians—they are university graduates—who earn £12,000 or £13,000 a year. There is a huge need for better pay and conditions for staff in London.

I take a deep breath before I mention hospital consultants. I shall qualify my remarks by saying that the vast majority of hospital consultants—I am married to one and I know many of them—are decent people who do an amazing job and work extremely hard. The British Medical Association will tell us that independent research carried out for the doctors and dentists review body by MORI in February 1999 showed that hospital consultants worked on average 50 hours a week in the health service, and that is not bad. Surgeons and anaesthetists work between 40 and 70 hours per week in the health service.

The research does not break down the figures for London and it does not go into much detail on them. I have had experience of the health service for 30 years and I know exactly what is involved. In the London area, consultants have a huge opportunity for private practice and their contracts are arranged in a rather odd way. One can be a full-time consultant and work eleven elevenths of one's time, because the contracts normally include Saturday morning. That still enables consultants to practise privately, provided that they do not earn more than 10 per cent. of their health service salary. I would not accuse consultants of fiddling their tax; I am sure that they do not do that. We must accept that they work their eleven elevenths in the health service, put in many hours and earn only 10 per cent. extra.

However, many consultants opt for another contract. It is a nine-elevenths contract which gives them two free sessions a week in which they can practise privately. Some say, "Okay. On Wednesdays and Thursdays, I work in the private sector, but I work for the NHS for the rest of the week." Many consultants work that way and it is absolutely fair and above board. However, there are a number—I know because I have worked in the NHS—who spread the two sessions over lunchtimes, early mornings, evenings and any other time when they get a senior registrar to cover for them. I could tell all sorts of anecdotes and tales of consultants who are not in NHS hospitals as much as they should be, but who can always be found in private hospitals. The problem of consultant contracts must be addressed for the sake of the future of the medical profession and the reputation of consultants.

Mr. Hammond

Obviously, no one condones anyone who seeks to cheat the system. However, for the sake of balance. Will the hon. Lady tell us whether she is aware from her personal experience of the surgeons and anaesthetists who would like to carry out more NHS work, but who are unable to do so because of the rigidities relating to support staffing and operating theatres?

Dr. Tonge

I entirely accept that point and I am glad that the hon. Gentleman has raised it. Consultant contracts are not the only problem. Many consultants are forced not to work for the health service because of the non-availability of an operating theatre owing to the closure of hospitals and the lack of provision in the hospitals that remain, or to the lack of staff or beds. I shall return to that point later, which, if not the only reason, is one of the reasons for the problem that has been described.

I represent a well-heeled constituency and when my constituents see a consultant, they are disturbed when they are invariably asked whether they want to be seen privately. If they do, they are told that they can be seen tomorrow or the next week. If they do not, they have to spend 12 to 18 months on the waiting list. That makes people suspicious and upset. If the same consultant can operate on them next week, why cannot they be operated on under the health service next week? Why do they have to wait 18 months for the same man to carry out the operation?

Even more ridiculous things happen in specialisms such as diagnostic radiology. I know of a consultant in a hospital not far from here who sees all the private patients and carries out all the investigations on the private patients that are referred to his department. The patients are referred by general practitioners and other doctors from all over the region and the managers love that because it brings revenue into the hospital. The consultant takes his fee from the patient and then returns a little whack to the hospital for the use of its facilities. Consultants who see private patients who have jumped the queue in the health service cause health service patients to wait much longer for their investigations.

In the hospital that I have mentioned, there is not a particularly long wait for the investigations; it has plenty of capacity. However, a young woman in my constituency has had to wait nine months for a pelvic ultrasound examination. That is ridiculous when private patients can be seen in an NHS hospital just five or six miles away and have the same investigation carried out within a week. That cannot be right, so I urge the Government to tackle that problem.

I suspect that I shall not have any friends or colleagues left if they get to hear about what I have said this morning, but—to be really nasty—the consultants who carry out the most work in private practice are, sadly, the consultants who receive the biggest merit awards. The more doctors and surgeons one knows and the more one is a member of the private practice referral club, the more likely one is to be nominated by one's colleagues for a merit award. That fact must be aired publicly, so I put my head on the block by airing the issue this morning. The Government must take that problem on board.

There is no shortage of consultants in London and there is certainly no shortage of beds and facilities; there is loads of spare capacity in the private sector. If the Government are serious about reducing waiting times and waiting lists, they have two clear options. They can use the private sector for NHS patients and let Sir Lancelot Spratt take his patient for a hip replacement down the road to a private hospital if he cannot do the operation in an NHS hospital—and why not? Alternatively, we should tell consultants that if they work exclusively in the health service where they will be given more beds and better facilities, they will receive much greater rewards than they currently earn.

Most NHS consultants receive consultant pay, not consultant. Pay plus merit awards. Therefore, their pay is not comparable to that of lawyers, who probably earn two or three times as much they do. In addition, lawyers do not suffer from the angst and are not subject to the flak that consultants have experienced in recent years.

Mr. Hammond

Does the hon. Lady not see a potential danger in inviting the most eminent surgeons to make the choice that she has described? There is the risk that they will be lost to the health service altogether. I have always found it a rather attractive feature of the health service that a surgeon who charges a high fee to see a wealthy patient from overseas in the morning will work in the afternoon seeing patients free at the point of use in the health system. Is that not a strength of our system?

Dr. Tonge

It is a strength of the system, provided that it is not abused. My contention is that the majority of consultants probably do not abuse it. However, those of us who have worked in the medical profession know that it is abused. Often, when an eminent person is seeing a patient in his private rooms, his senior registrar and junior staff may be coping like Trojans in his out-patient clinic in an NHS hospital. That needs to be examined carefully and tactfully. The Government must recognise that consultants need better rewards than they currently receive in the NHS if they are to compare with other specialties and are to continue to take the risk of doing complicated procedures that may sometimes lead to a patient's death. However, both options cost money.

I am sorry to have taken so long, but I shall conclude with a point about funding, which relates not just to the health service in London, although it affects us acutely. The health service cannot go on without secure guaranteed funding every year, and funding must not depend on the whims of the Government, focus groups or whatever we think will give us enough political kudos. The health service needs far more funding than the Liberal Democrats have ever proposed and more than the Government are planning to give it. Indeed, it needs more money than any political party is prepared to take out of direct taxation. That is the problem: no one is honest enough to tell the British people that if they really want the sort of health service to which they aspire, it will cost them money. It would actually be much cheaper to pay far more in taxes than to take out private health insurance, perish the thought. The problem is never declared openly and we desperately need a debate about how we will fund the health service in future.

Mr. Deputy Speaker (Mr. Frank Cook)

There are seven speakers to get in if everyone who wishes to make a contribution to our debate is to be satisfied. I must therefore alert the Chamber to the fact that I shall be looking for concise, pertinent and clear statements that do not take an awfully long time.

11.22 am
Mr. Gareth R. Thomas (Harrow, West)

As is traditional, I congratulate the hon. Member for Richmond Park (Dr. Tonge) on securing the debate. I agree with her concerns about mental health beds in the capital and think that her point about them was particularly important, although I suspect that the thrust of her other remarks will get the most attention. I share the general view that the amount of private work done by a small number of consultants needs to be examined by the Government. I understand that that is happening, but the Minister may be able to comment further.

I welcome the debate as it is almost a year since we last debated London's health services, on a Government motion in an Adjournment debate. Today's debate gives us an opportunity to see how London's health services have progressed in implementing the Government's health reforms. This time last year, the key strategic issue facing London was how to inculcate the principle of partnership. The hon. Lady's experience of two local hospitals battling for supremacy is one with which my constituents would have considerable sympathy. In our debate last year, I said that, at times, there seemed to be a sense of bureaucratic imperialism in the health service, with the chief executive of an acute hospital battling with the chief executive of another hospital over services that they wanted.

How have matters developed in the past year? I shall give local examples and discuss the atmosphere now prevailing in Harrow's health care services, which have embraced the Government's national priorities with enthusiasm. In relation to national priorities on heart disease and strokes, the Harrow West primary care group has agreed local development schemes and incentive targets with all GPs and practices in the group. The GPs have identified all the patients on their lists at risk of heart disease, strokes and diabetes. There are now proper records and monitoring of the treatment of those patients. There is new investment by the primary care group in clinics, and staffing levels to meet concerns about heart disease, strokes and diabetes.

Another positive development in health prevention is the recent launch of the Harrow Heartbeat health campaign, which is a multi-agency primary prevention exercise aimed at raising public awareness of how to avoid heart disease and diabetes. The primary care group has worked to develop better access to care and has been successful in extending psychological counselling, for example. There used to be only 13 practices with access to such counselling; now all 27 practices in the primary care group have access to such services.

Practice-based mobile ultrasound services have been extended from two primary care teams to 22 practices in the primary care group, and local waiting times have come down from 11 weeks to two weeks, easing considerably the pressure on hospital ultrasound services, especially at Northwick Park hospital. All practices are now able to carry out cryosurgery—surgery on bumps and lumps—which, again, eases the pressure on hospital out-patient referrals. There have therefore been positive local developments on better access to care for patients.

Most significantly, £2 million is being invested in Northwick Park hospital's accident and emergency unit. That investment has been needed for at least 10 years and is only taking place thanks to this Government. The newly refurbished unit should be open in September. Furthermore, £5.8 million is due to be invested in two linear accelerators at the Mount Vernon cancer unit, which will substantially improve the quality of cancer care available to my constituents and others in the region who benefit from the hospital. It will also give my constituents much-needed reassurance about the future of Mount Vernon hospital.

There is considerable concern nationally about quality of care, not least in the light of what is taking place on the issue at the General Medical Council this week. In my constituency, the primary care group has delivered a clinical audit covering all GP practices, and a second audit is due to take place. Proper peer review visits are being made to all the primary care practices. There have therefore been good and positive developments in both primary and secondary care in my constituency.

We have done a lot, but I want to highlight one or two matters on which further work must be done. I spoke in the Easter Adjournment debate to highlight the need to expand the provision of intensive care beds at Northwick Park hospital. There is an urgent need for significant investment in intensive care in outer London, so that my constituents and their relatives do not have to travel into central London to benefit from the intensive care services there.

Northwick Park hospital is ideally placed to benefit from additional investment in intensive care. It is a fully staffed unit. Northwick Park is probably one of the most successful hospitals in London in maintaining a full staffing complement for its intensive care needs. However, the existing facilities are not adequate to meet the local demand. I hope that the Minister will convey as a matter of urgency to her colleagues the need to accept and recognise the business case for an expansion in intensive care beds at Northwick Park.

Another local issue in Brent and Harrow is a review of the capitation process and formula. Under the present formula, Brent and Harrow is considered to be above its target so we tend to receive less growth moneys than other districts. The skill of many of the people who work in the primary care group, the health authority and the local trusts has meant that we have been successful at winning new funds for the NHS locally, but a review of the capitation formula needs to take place. I, for one, do not accept that the formula properly reflects the needs for health care in Harrow.

Recruitment and retention of nurses have received substantial attention in other debates both in this Chamber and in the main Chamber, but recruitment and retention of support workers are equally crucial to the quality of care. I am thinking of cardiac technicians and technicians who work in the delivery of pathology services. The pay and conditions of those professionals need attention.

I suggest that we need some more investment in the assistance that we offer to patients who think that they have not received good service from the NHS. In my constituency, the son of a woman who died had some genuine concerns about the quality of care that she received from one of my local hospitals, but he had and still has problems in obtaining access to medical expertise to advise him and help him read the medical records available to him and judge whether there was significant substance to his concerns. We have done a great deal to improve London's health service and health care for my constituents, but there are other things that we need to do, and I hope that the Minister will take those concerns forward.

11.33 am
Mr. John Randall (Uxbridge)

I congratulate the hon. Member for Richmond Park (Dr. Tonge) on securing this debate. The attendance shows how popular the subject is and the need for the debate. Perhaps I can make a plea to the Minister. The hon. Member for Harrow, West (Mr. Thomas) said that a year ago we had an Adjournment debate in Government time on health services in London. I suggest that a proper debate on the Floor of the House is about due. We do not want to have any more waiting for that.

The hon. Member for Richmond Park raised one issue about which I have a genuine question. I am not too up on it and perhaps she can give me an answer. I understand that if a GP holds only computerised records and not hard copies, he or she is in breach of some regulation, and that that deters many GPs from computerising records.

In Hillingdon, we have recently had the arrival of the primary care trust—one of the few in London. It is early days, but it has been greeted by most of the people in the health agencies with open arms. It seems that, although it is early days, the enthusiasm and optimism shows that PCTs might well be appropriate in certain areas, certainly in suburban and urban areas.

I and the two other Members of Parliament for the London borough of Hillingdon had a meeting last Friday with all the health agencies, including the community health council, to find out whether there was a cunning plan for Hillingdon. We feel that we are just drifting. We were slightly reassured. We are having a further meeting, but there is a great willingness to work together. We were told by someone from outside the area that Hillingdon is a good example of an area in which everyone is working towards a common goal. The social services department is working closely with the health agency to try to resolve some of the problems that we know exist.

We are not entirely sure what the big plan is for Hillingdon. We have our own vision and ideas of what we want and expect for NHS patients in three or four years' time. Although many matters teed to be dealt with for the time being, we also want to look to the future. We are worried that once we have our own plan, regional and perhaps national plans will be changed.

If the hon. Member for Hayes and Harlington (Mr. McDonnell) were here, I am sure that he would raise the problem that he has and that I share in the Uxbridge constituency—the problem of GP practices. As time is short, I will make passing reference to the work that my hon. Friend the Member for Ruislip—Northwood (Mr. Wilkinson) has done in promoting the problems facing Mount Vernon and Harefield hospitals, which were mentioned briefly by the hon. Member for Harrow, West.

There is a great deal of concern locally—when I say "locally" I mean over quite a wide area—about threats to close those two hospitals. I cannot single out either of them, but Harefield is regarded as a national asset, and I find strange the idea that it would improve people's health to take them into the inner city for their operations and recuperation. Anyone who has been to Harefield knows what a tranquil and idyllic spot it is. Even a layman such as I realises that being in a place like that aids recovery.

As time is short, I shall not rehearse the points about Mount Vernon. I mention only the A and E unit, which has gone, and the burns unit and the cleft palate unit, which are under threat. There is a strong feeling locally that consultation with local interested parties is consultation for the sake of it. It seems that the decisions have already been made. Whether that is true remains to be seen, but there is a strong feeling that the consultation is just lip service.

I share many of the concerns expressed by the hon. Member for Richmond Park. I have many of the same problems, including recruitment and retention. The hon. Lady mentioned the TB vaccine. I have taken up the issue and found out that there has been no routine BCG vaccination of children under the schools programme in Hillingdon for the past two years. In a letter dated 21 January 2000, I was told that this was due to the non-availability of BCG vaccine. I should like to know from the Minister whether there has been any improvement and what the Government plan to do about the problem. Are there any plans to vaccinate people who missed out? In that case, there will surely be a huge backlog. In the light of increasing incidence of TB, what threat is there to those children who have not been vaccinated? Do the Government consider the vaccination to be as vital as do the parents of those children who have not been vaccinated? I hear little on the subject from the Government, and I hope that today we shall hear more.

As Members of Parliament, we hear only the complaints, sometimes serious complaints, that come to us, so it is easy for us to think that everything is doom and gloom. Many questions surround the NHS in London. I pay tribute to all those people who work in the health service in Hillingdon, who are doing their utmost, sometimes in difficult conditions. There are some good things going on; I particularly mention the diabetes unit at Hillingdon hospital, which is certainly first class.

I regret that, as a Member of Parliament, I have spent the past three years or so fighting closures in the local health service. I should like to be welcoming the arrival of new services. It is a great shame that most Members of Parliament have been fighting such causes for some while. I make a special plea for increased renal services in our area. There seems to be a dearth of such services in west London—particularly of dialysis, but in a range of other services, too.

I am sure that the Minister is aware of the great disappointment and frustration, not only in my area and in London generally but throughout the country, about what is happening in the NHS. If we are not careful to address those concerns quickly, there really will be a crisis. I do not want to talk up crisis for party political gain, but if she walks the streets, she will find that that is what everybody is saying.

11.41 am
Mr. Barry Gardiner (Brent, North)

I, too, congratulate the hon. Member for Richmond Park (Dr. Tonge) on securing this vital debate. It is vital in the true sense of that word because it concerns the life and death of our constituents here in London.

I must disagree with the hon. Lady on one specific point. Early in her speech, she made a plea for no more change in the health service. I want more change; I want the sort of changes that we are seeing at Northwick Park hospital accident and emergency department. It was originally designed 30 years ago to accommodate just 40,000 attendances a year, but in the past year, that A and E department saw 75,000 people through its doors.

Dr. Tonge

I must qualify the point. There is great difference between reorganisation of management structures and new facilities that will affect patients.

Mr. Gardiner

I understand very well the hon. Lady's point. Indeed, were there time, I would elaborate on it.

I am delighted that we have secured the £2.2 million from the Government modernisation fund to make the change that is needed. Work has already begun. It includes a new six-bed resuscitation unit, a dedicated child care service, 22 new major injury bays, new minor injury bays and accommodation in the new A and E department for 90,000 attendances—more than doubling that of the present design and allowing for a 25 per cent. increase on throughflow. That is the sort of change that I welcome, and I am sure that the hon. Lady would do so, too. It is the sort of change that I want more of.

As anyone in Brent will tell you, Mr. Deputy Speaker, the overcrowding of the A and E department at Northwick Park was desperately exacerbated by the scandalous closure of the emergency unit at Edgware hospital, which was rushed through by the Conservative Government just one month before the election. My greatest disappointment since becoming a Member of Parliament has been to find that we could not reverse that decision.

We had pledged to review the closure. It was only after the election that the true extent of the deviousness surrounding that closure became apparent. The Tories had not just closed the A and E department; without telling the public, they had let the contract to demolish the surgical block. Without surgical back-up, it is of course not safe to have an A and E department. The promised review therefore could not restore the emergency unit. That is the sort of change that I did not want.

Together with other local Members of Parliament, I spoke to colleagues in government—indeed, to the now Secretary of State for Health—and secured for the hospital another review of all the services that were to take place on the site. The full business case for the redevelopment of Edgware hospital has now been approved at a capital cost of £21.8 million. That is £22 million of new money going into services and provision for the local community in Edgware, Brent and Harrow.

A pilot of a primary care walk-in centre will open in August. The new hospital will include consultant-led out-patient services, children's services, day surgery and a birth centre. Those are all changes in the health service in the Brent and Harrow area that we want and on which we welcome the Government's initiative.

However, there are other aspects of the service in Brent and Harrow which the Government must address and change. I believe that the Minister knows of my concern, which is shared by my hon. Friends the Members for Harrow, West (Mr. Thomas) and for Harrow, East (Mr. McNulty), about the provision of breast screening by the Brent and Harrow health authority.

Women should receive reports of abnormal results from breast screening within two weeks. In fact, the results are reported within four weeks. The Government set a target for assessment of abnormal results within two to three weeks. The time span is up to six weeks. That is a desperate situation for women who are concerned about an abnormal scan and who want to find out what is going wrong and what treatment they might be able to receive. Mobile units in the Brent and Harrow health authority are clapped out. There is one left that is working. I challenge anyone to say that a screening unit that has for five months stood in a car park in Stanmore is truly mobile.

Those are the sorts of problems with which we are dealing, and they must be addressed by the Government. I know that ministerial colleagues are committed to providing good oncology services and that screening is one of the most fundamental parts that is subject to the review that the Department is undertaking, but I urge the Minister to respond to the concern of all local Members of Parliament and to ensure proper provision.

I shall finally pick up a point made by the hon. Member for Richmond Park on the curse of tuberculosis. She talked of it as one of the most fundamental indicators of poverty. She may or may not know that my constituency has the highest incidence of TB. I raise the point because, although otherwise correct, her remarks cannot apply to Brent, North.

Brent, North is a comparatively affluent constituency, but 40 per cent. of its population comes from the Indian subcontinent, and they return there frequently. The health authority—I have been in discussion with it—is convinced that the real problem is with the Indian community visiting family on the subcontinent, where conditions are as the hon. Lady described, contracting TB and returning with the infection. I share her deep concern about the matter, but incidence of the disease in my local community is not indicative of poverty.

If time permitted, I would comment on many other issues. In particular, I welcome the reduction in the waiting lists in the Brent and Harrow health authority at Northwick Park from 11,500 to 8,500—a 25 per cent. reduction during the past three years. However, I am conscious of the time, and I know that other hon. Members wish to speak.

11.50 am
Mr. Andrew Love (Edmonton)

I add my congratulations to the hon. Member for Richmond Park (Dr. Tonge), and apologise for arriving late and missing the start of her contribution

. I shall focus my brief remarks on an issue of major importance to the health service in London—the balance of funding between primary care services and the acute sector. Hospitals have always been synonymous in the public mind with the health service, but most people look to primary care—in many ways the cinderella service—to deal with their health care needs.

The balance of funding has been a problem in London since the advent of the national health service in 1948. A major recommendation of the Tomlinson report in 1992 was that there should be a shift of resources from the acute sector to primary care. It was suggested that that should be achieved through a reduction in bed numbers. I shall not elaborate on the problems that that has created in London, but the report recognised the difficulties of funding primary care and the provision of GP services in the Greater London area, which was identified as a major problem by the hon. Member for Uxbridge (Mr. Randall).

The Tomlinson report made a number of recommendations for improving the number of GPs, the associated services provided by health centres, and GPs' premises. However, it is clear from the Turnberg report of only two years ago that the problems of primary care in London continue and in many ways intensify. Since 1990, GP numbers in London have fallen by 1 per cent., during a period when they have risen by 6 per cent. in the rest of the country, and at a time when the population of London is increasing.

There is a particular problem with single-handed GP practices. Whereas they have reduced to 8.6 per cent. of all GP practices in the rest of the country, in London they represent 20 per cent. of practices—a major issue for London health services.

With regard to list sizes, the number of GP practices with lists of more than 2,500 is much greater than in the rest of the country. I recognise that there is far more population movement in Greater London, so some lists may well be inflated, but the pressure on GPs in London is significantly greater than on those in the rest of the country.

The problem of GP premises was supposed to have been addressed by the Tomlinson report in 1992, but in my district, Enfield and Haringey, 55 per cent. of GP premises remain below the minimum standard.

Taking all those difficulties together, we can understand why Leslie Turnberg stated in his report: General practice lags behind the rest of the country and appears to be getting worse rather than better. The problem is not just the failure to attract GPs into Greater London. There is a series of associated problems, often but not exclusively related to single-handed practices. I refer to the additional services that we have come to expect from health centres—the provision of practice nurses, chiropody and so on. Those are not provided in Greater London, as they are in other parts of the country. The training of staff to provide those services is not being achieved in Greater London, partly because of the number of single-handed practices, and partly because of a lack of commitment to maintaining staff of the highest standard.

The professional development of GPs is a further issue. Many single-handed GP practices in London are run by elderly general practitioners, many of whom have never had to update their skills and are still practising as though the health service was still in the 1950s and 1960s, rather than going into the 21st century.

The provision of proper primary care in the most deprived areas has been a particular problem. The difficulty of attracting GPs to deprived areas was partially addressed by the Government in 1998, when they made available £25 million for additional deprivation payments. I welcome that, but there are continuing doubts. It is clear in London and other parts of the country that deprived areas face significantly greater problems in attracting staff.

I recognise that a salaried general practitioner scheme may overcome some of those problems, but we must find ways of attracting GPs to work in those areas. The way in which the payments scheme operates is not to the advantage of the service. There seems to be some confusion about whether the payment is for additional work load, for providing additional time for the patient, or to attract staff into less attractive areas.

I urge my hon. Friend the Minister to re-examine the deprivation payments scheme, to see whether there is anything further that the Government can do to ensure that our most deprived areas—those that have been the focus of the recent report entitled "A National Strategy for Neighbourhood Renewal"—will be able to offer a level of service comparable with that available in other parts of the country.

Finally, I hope that the spending review will address the balance of funding between primary care and the acute sector. Tomlinson got it entirely wrong by suggesting that resources should be shifted across the two. With the additional resources that are to be made available, there is an opportunity to provide an adequate level of funding for primary care. If we do that, we may create a health service in London that meets the real needs of its people.

11.58 am
Mr. Paul Burstow (Sutton andCheam)

I congratulate my hon. Friend the Member for Richmond Park (Dr. Tonge) on securing the debate. It is a timely debate, following on, as others have pointed out, from a debate in Government time about a year ago. From the contributions that we have heard today, it is clear that it would be valuable if there were a further debate in Government time, so that more hon. Members—London Members in particular, but others, too—could contribute.

Speeches have reflected a range of constituents' experiences and the concerns of professionals in the health service. As the hon. Member for Uxbridge (Mr. Randall) rightly said, in our mail bags we receive and pass on many brick bats; we receive fewer bouquets. However, much of what the national health service does in London and elsewhere is excellent and needs encouragement, promotion and further development.

My hon. Friend the Member for Richmond Park has raised several important issues. I want to mention some, and develop a couple of other themes that emerged from the debate. She was right to mention the huge health inequalities that exist in London and the litany of reports that have identified the strong relationship between poverty, deprivation and poor health, and the need to do more.

My hon. Friend was right to highlight bad practice and corner cutting, as she put it, that is caused by an obsession with bed occupancy rates. The fixation with bed occupancy statistics, and efforts to concentrate on conditions rather than the person as whole, can lead to lack of attention to detail in the care of an individual, often at the expense of that person's dignity and overall care.

My hon. Friend identified another problem, which applies to my constituency. She spoke of change that is not about investment in services, which the hon. Member for Brent, North (Mr. Gardiner) rightly described and welcomed, but organisational change. The NHS appears to be in perpetual revolution. It perpetually changes its organisation and management structures, not always with the outcomes trumpeted by the Ministers who initiated them. The primary care groups and primary health teams in the latest review are useful to drive primary care, but I am worried about the lack of integration of health, especially primary care, with social care. In my constituency, there is a lack of coterminosity between primary care groups and social services departments. That could get worse.

My hon. Friend said that she was making a Back-Bench speech. She made a typically forthright speech and raised many issues that will continue to be debated in this place and outside for some time. She was especially right to consider staff vacancy rates. It is important to acknowledge that capacity is vital in dealing with many anxieties that are raised with us in our constituencies. We have only to consider the legacy of staffing in the NHS to appreciate that the problems with which the Government grapple did not necessarily begin on 1 May 1997. They were long in their manufacture under the previous Government's tenure. We have only to consider the age profile of many staff, especially nurses, to realise that the current problems are not likely to be solved for some time. Many staff are approaching the end of their time in nursing. We must acknowledge that when considering the resources for tackling vacancy problems.

London suffers from the most acute staff shortages in professions allied to medicine and in nursing. One in three of the 15,000 vacancies throughout England are in London. The three-month vacancy figures for nurses and midwives show 2.6 per cent. in England and 5.1 per cent. in London. The figure in my health authority is 4.9 per cent; in my local Epsom and St. Helier trust, it is 6 per cent. Managers are grappling with genuine problems. They have to go ever further afield. Reports in the Evening Standard show that they look not only further afield in this country, but abroad to try to find additional staff to plug the gaps.

The hon. Member for Harrow, West (Mr. Thomas) mentioned the need to invest in intensive care services. I agree, but we must acknowledge that there was intense pressure on intensive care beds in London last winter and that that was caused, at least partly, by staffing problems. There are 20 per cent. vacancies in intensive care units in London. The problem is therefore not simply one of beds and units. However, the hon. Gentleman was right to point to the need for investment in such services in outer London.

The problem of vacancies is caused partly by the fact that people are being priced out of London. That applies to public sector workers generally, and especially NHS staff. In the past year, house prices have increased in London by 23 per cent. It is a harsh reality that a newly qualified nurse, who earns approximately £17,000, cannot get on the property ladder. As my hon. Friend the Member for Richmond Park rightly said, our benefits system makes it difficult even to get into the rented sector.

I want to address two other issues briefly. First, I want to speak about neurology, another Cinderella service which needs some attention in London. I understand that a review is currently taking place. I hope that it will shed light on the way in which the services might be developed in future. Specialist services have suffered through reorganisation and fragmentation. It is therefore important to consider the way in which we can tackle that.

Probably more than one in 30 people in London are affected by neurological conditions. There is only one neurologist per 200,000 people in the United Kingdom. I suspect that the position may be worse in London. There are not enough neurologists to fulfil demand. I undertook a survey earlier this year and found that the average wait for a first appointment with a neurologist was 19 weeks. The longest waits were 23 weeks. That is unacceptable when trying to map out the necessary care pathways to provide support, care and attention. Indeed, in this country, patients who sustain a head injury or stroke have half as much chance of waking with a neurologist or a neurosurgeon at the bottom of the bed than anywhere else in the developed world. That is an unacceptable measure of our position as a country.

Many neurological conditions leave people feeling marginalised and left to navigate their own way through the care system. Early diagnosis is vital; it leads to a better prognosis. Clear care pathways and counselling are often the key to many neurological conditions. Greater co-ordination of service providers and a multidisciplinary approach are essential. I hope that the Government will consider developing not only the strategy that is being worked on in London, but the need to provide a national service framework to develop neurological services.

Secondly, I want to speak about communicable disease, to which the hon. Member for Brent, North and my hon. Friend the Member for Richmond Park referred. I shall concentrate on mumps, measles and rubella, and tuberculosis. There is a strong correlation—although the hon. Member for Brent, North cited some evidence to contradict it—between deprivation, low immunisation levels and outbreaks. That is not surprising when we take into account that 11 out of the 20 poorest boroughs in England are in London.

Let us consider TB first because mortality rates in London are a serious problem. Incidence of TB in London is 80 per cent. above the national average. Incidence is concentrated in some of the most deprived parts of London The hon. Member for Brent, North identified other reasons why it is a problem in Brent. There is also a serious problem in east London. The incidence in east London is six times the national average. The hon. Member for Uxbridge is right to draw attention to the backlog of BCG vaccinations and the potential problems that that could cause, for example, a future increase in TB.

The recommended level of immunisation to avoid outbreaks of mumps, measles and rubella is 95 per cent. In the United Kingdom, take-up is 88 per cent; in London, it is 80 per cent. However, like any average, that figure hides wide variations. In some parts of London, the figure is as low as 71 per cent. Outbreaks occurred in east London last year. They were not major or life threatening, but they are a serious cause for concern when we consider that serious outbreaks occurred in the Netherlands, where immunisation levels are too low. Consequently, the more fatal elements of the condition were reached.

We need a concerted campaign to increase immunisation. Even if poverty is not the cause of outbreaks, low immunisation is a major reason for the increase in outbreaks. We need to consider carefully what immunisation levels in London mean for outbreaks in the next five to 10 years and ensure that we put that right now.

This debate has been a useful taster of the fuller debate that I hope will be allowed in Government time because many issues need to be discussed, including high-tech investment, about which hon. Members have spoken, and the need to deal with the detailed care of individuals. As my hon. Friend the Member for Richmond Park has said, the statistics on health inequalities in London are striking. Those inequalities need to be acknowledged in allocating resources and using existing resources more effectively, which means considering how to improve capacity without losing sight of Cinderella services, such as neurology. We must ensure that we drive home the message about immunisation and the links with poverty and communicable diseases so that health in London is as good as anywhere else in the country.

12.10 pm
Mr. Philip Hammond (Runnymede and Weybridge)

I apologise to hon. Members for my late arrival. I had not realised until today that debates in Westminster Hall could start before the allotted hour. I, too, congratulate the hon. Member for Richmond Park (Dr. Tonge) on securing the debate. She seemed to be slightly torn between the temptation to attack the current Government and the temptation to attack the previous Government, so she had a go at both, safe in the knowledge that the party that she represents is unlikely to be burdened with that responsibility.

We have had a good debate, and hon. Members have made some important and interesting points, to which the Minister will want to respond. London is different. London's size, population density, ethnicity mix, social problems and environmental characteristics provide a specific backdrop to its health agenda. Many of the issues that hon. Members have raised reflect the more general problems of the NHS across London.

The hon. Member for Edmonton (Mr. Love) made the point, which I am fond of making, that we as politicians are guilty of a tendency to focus on hospitals and acute services, yet primary care and community services represent the routine point of contact with the NHS for the great majority of people. A health agenda that works for Londoners must address the inadequacies in those services and provide people in the heart of the capital with the same quality of primary and community services that those who live on its periphery and in the surrounding suburbs have come to expect. Until the primary care tier is right, the secondary sector will always struggle to do its job properly against a background of inappropriate referrals and self-referrals to hospitals.

The hon. Member for Richmond Park referred to the huge additional burdens that the influx of asylum seekers have put on health services in London. That is an example of the specific problems that London faces. The incidence of TB is soaring. One estimate suggests that TB could have increased by 80 per cent. in 1999 alone, which inevitably imposes a huge burden on the service. There are other pressures, including HIV. A third of all HIV suffers in the United Kingdom live in London. The number in south-east London alone has increased by a third in the past two years, yet, for example, the genito-urinary medicine clinics at Guy's and St. Thomas's are forced to shut their doors once they have seen 100 patients because of the lack of resources. Facilities are not being used to address the urgent problems that face the capital.

Substance misuse and mental illness are particular problems in London, as hon. Members have said. Those problems affect twice as many male London residents compared with the United Kingdom average. Health authorities in London are inadequately resourced to deal with those specific problems, often with the result that improvements in basic health services for Londoners are not taking place as fast as in other parts of the country or as fast as necessary.

I am very concerned that the consensus by which the NHS prospers and has worked for the past 50 years will start to break down if what I shall typify as the ordinary working Londoner finds that the health services cannot deliver for him and his family, that the accident and emergency department cannot respond when his child needs it and that the family health services are not there for him and his family when they need them because of the extraordinary burdens that face the health care system in London. In addressing the specific needs involved in mental illness, HIV, sexually transmitted diseases, TB and so on, it is important that we do not lose sight of the fact that we have to preserve that consensus by providing appropriate services across the board.

Outer London has some of the longest A and E waiting times and, on average, London as a whole has longer waiting times than the rest of the United Kingdom. That is linked to the problems of staff recruitment and retention. Some London trusts are 30 per cent. under establishment in nurses and are surviving only by using agency and bank staff.

The hon. Member for Richmond Park described the problems facing student nurses on bursaries. I have seen examples of such problems in my constituency, where house prices are almost as high as in hers. That urgent problem needs to be addressed. I do not pretend to have an instant or easy answer, but it is vital that it is resolved so that the health service in London has a future.

The hon. Lady also dealt with bed-occupancy rates—obviously, a critical issue given the rising number of hospital-acquired infections, yet the Government are still closing beds. According to The Sunday Times last Sunday, that has led to scenes of third-world chaos and squalor at a major teaching hospital in London.

On the eve of the election, the Government's slogan was "24 hours to save the NHS". Now that they are in office, they seem to be slightly less pressured by time. In response to the Turnberg report, the then Secretary of State, the right hon. Member for Holborn and St. Pancras (Mr. Dobson) said that it would take 10 years to improve London's health services, but, in the meantime, the NHS is still failing Londoners too often. Deficits are piling up in health authorities and trusts.

The Government promised a moratorium on hospital closures, but, after their three years in office, the axe still hangs over several London hospitals and beds are whittled away in others. Other hospitals have gone. Bart's—which was supposedly saved for the community and which, we were told, would focus on cancer and cardiac services—will not be a general hospital serving the local population, but a specialist unit. To all intents and purposes, for local people, Bart's has closed—a triumph of spin over substance and another broken election pledge.

The Harold Wood hospital scheme has been scrapped. The Havering hospitals NHS trust has now conceded that the new Oldchurch hospital will not be completed before the autumn of 2005, and people close to that situation believe that 2007 is a more accurate estimate. A further 200 beds have been cut from the planned number at the Royal London hospital development and the split-site solution has been chosen. Senior consultants have condemned that decision as a "dangerous" political fix, which presents a "serious risk" to patients.

The hon. Member for Richmond Park has spoken about the situation at Queen Mary's hospital, Roehampton. Ambulance response times there were only 26 per cent. compliant with the Government's target, which had knock-on effects in maternity and A and E services across west London. Services at the Royal Free, Whittington and other hospitals are facing continued threats and uncertainty.

What of the future? The fact that London has an elected Assembly and an elected mayor has not been mentioned. They are bound to want to have a say in the health agenda for London. Across the country, political interference and attempts by politicians to micro-manage the health agenda have been part of the problem, not of the solution. I hope that the Minister will reassure us that the NHS in London will not be turned into even more of a political football when the clash of titans takes place as the mayor gets into his stride.

The Minister needs to tell us that the extra money that will be made available to London during the next three or four years will reach the health authorities and can be used to improve primary and secondary services so that ordinary, hard-working Londoners can be confident that the NHS in London will be there for them when they and their families need it. After all the other extraordinary pressures that are specific to London have been dealt with, the ordinary people of London must find that the services that they need exist so that the consensus that is essential for the NHS to survive and prosper in the 21st century can be rebuilt.

12.20 pm
The Parliamentary Under-Secretary of State for Health(Ms Gisela Stuart)

I congratulate the hon. Member for Richmond Park (Dr. Tonge) on securing this timely and useful debate. Up until the last 10 minutes, I thought that it was specific to London, and I wish that I had more time to respond to the points that she raised. I realise how busy she has been this morning, as I saw her taking part in the earlier debate on Christians in Egypt. Her concerns go well beyond her constituency.

I shall deal with the specific points before coming to the more general aspects. Consultation is part of the national development plan. Some people have said please, no more change, and others have said that they want more change. I think that we need both. We need continual change, but it must be part of a much wider, strategic framework.

The hon. Lady referred to bed occupancy rates. I am aware that there have been problems with bed occupancy in hospitals in her constituency. However, I understand that they have now been alleviated. Kingston hospital has 30 more acute beds than it had last year, and the provision of mental health beds at Queen Mary's University hospital in Roehampton has improved because alternative provision and arrangements have been made at Tolworth hospital.

I was grateful that my hon. Friend the Member for Harrow, West (Mr. Thomas) recognised the improvements that have been made, but he highlighted the issue of intensive care beds, especially in Northwick Park hospital. I understand that he has a meeting tomorrow with the regional director of the NHS executive in London. I hope that he will have a successful exchange of ideas.

The hon. Member for Uxbridge (Mr. Randall) was concerned about whether consultations in this area are real consultations. I point out that the Mount. Vernon hospital accident and emergency department was closed under the previous Government. We must not lose sight of the past. Closing accident and emergency departments is not a significant characteristic of this Government: we are concerned with the provision of services. The consultation process can sometimes be unsettling for communities. We seek certainty, but the very process of consultation involves a period of uncertainty until decisions are made.

Many hon. Members raised the subject of tuberculosis and the TB vaccine. We are fully aware of the problems. The Government are in discussion with the manufacturers about the national shortage of vaccine. I assure hon. Members that the Government have made sure that the available vaccine goes to the children who are most at risk. In London, where this is a specific problem, the Thames regional directors of public health in 1998 published "A strategy for tuberculosis control in London: a need for change". As a result of that, a taskforce was set up in consultation with multidisciplinary agencies. We are piloting a TB register in London, and we shall soon have some of the results of that scheme.

My hon. Friend the Member for Brent, North (Mr. Gardiner) reminded us of the disgraceful manoeuvring in relation to Edgware hospital, which made a revision of the plan impossible when we came into government. He raised valid concerns about breast screening in his constituency. I am fully aware of the number of parliamentary questions that he has tabled on that issue. If he would find it helpful, I should be happy to facilitate a meeting with Ministers to discuss the matter further.

My hon. Friend the Member for Edmonton (Mr. Love) expressed his concerns about funding for primary care. He explained the problems faced in many parts of the country, especially in big cities. As a Birmingham MP, I recognise some of the problems that he referred to, but not on quite the scale that people face in London. Considerable extra funding is going into the primary care sector, not least the £10 million additional funding in 2000–01 that has been targeted on improving primary care premises in London. I am sure that my hon. Friend welcomes the opening of the walk-in centre in Tottenham and Edmonton on 31 July.

The hon. Member for Sutton and Cheam (Mr. Burstow) referred to the problem of boundaries, which is almost insoluble. There will always be overlapping boundaries: there is no perfect solution. It is important in the establishment of primary care groups and subsequent primary care trusts that the configurations we end up with have a natural dynamic. Communities should have cohesion. Sometimes boundaries will be concurrent, but in other places they will not be. Where there are overlapping boundaries, especially between health authorities and social services, we want provisions to be put in place that will overcome the problem.

Like all of us, the hon. Member for Runnymede and Weybridge (Mr. Hammond) learned something new today. I hope that he welcomes that learning opportunity. We welcome such developments in the national health service. I must challenge his notion that the problems are due to inadequate resourcing. He rightly said that we need a national consensus for a national health service. If there is one party that is committed to a national consensus for a national health service out of taxation it is the Labour party. We do not think that private insurance is the way forward.

To come back to the overall problems, what the debate showed is that London contains an extremely diverse community. It does not have a static population: some 7 million people live in London, but 25 million tourists visit the city, some 670,000 commuters come into London to work and almost a million people travel into the city centre every day. It has great diversity, including some of the most deprived areas and some of the most affluent. It has extraordinary nationally and internationally recognised medical expertise, and some examples of the worst practice.

That is why one of the first things we did when we came into government was to establish the Turnberg review, which was an independent investigation into the needs of London. We also set up the NHS executive's London office. The Turnberg review reported in seven months, and the Government accepted all its recommendations. It is important in the London context that all the agencies work together.

Hon. Members raised the issue of mental health. It is important to remember that on 11 April the Minister of State, Department of Health, my hon. Friend the Member for Barrow and Furness (Mr. Hutton), launched "Mental Health in London: A Strategy for Action", which was developed jointly by the NHS executive and the social care regions. As the hon. Member for Richmond Park said, health and social care services must be delivered coherently.

These strategies are underpinned by increases in resources and the provision of new services. It is no accident that, of the 36 walk-in centres, a quarter are in London. The new services of NHS Direct will be available for the whole of London by 31 October. The Soho walk-in centre is important because it is a local health service centre that includes the Chinese national healthy living centre. That is a recognition of the ethnic diversity of London.

The funding that has gone into London has been unprecedented. There has been huge capital investment of £3.5 billion in a building programme, and there is year-on-year recurrent investment that is not used to pay off debts, as has been suggested. We expect any institution, whether it is a hospital or a trust, to finance its services coherently. In London, new moneys are certainly not being used to repay old debts. They are used to address the shortcomings in services, and to reconfigure services so as to provide a better service for everyone in London.

Focus is being put on health action zones working together with the new London mayor to provide a much healthier environment for people in London. We have recognised the need for strategic input, for extra money and for extra help for the training and retention of nurses. We are confident that we will put those policies in place.