§ 11 am
§ Mr. Tom Brake (Carshalton and Wallington)
I am grateful for the opportunity to start this debate. I shall concentrate on south-west London, but the concerns expressed there are representative of the whole of London. My hon. Friend the Member for Sutton and Cheam (Mr. Burstow) will focus on London-wide health issues.
What are the main health issues in south-west London? Primary care; the recent strategic direction discussion document published by the Epsom and St. Helier trust; the merger of health authorities; and the threatened closure of Orchard hill. A few weeks ago I secured a debate on Orchard hill, so I shall not raise it again today, other than to say that since that debate, I had a meeting with Peter Andrew, one of the parents fighting the closure. He remains worried, because if the site is closed, the idea of a home for life for residents in a secure and safe environment, allowing a degree of independence that could not be provided elsewhere, will be lost and parents' and relatives' wishes will be disregarded.
I should like to draw the Minister's attention to the volume of changes undergone by the local health economy. We recently had community trust and mental health trust mergers, but I shall not focus on them today. Currently, primary care groups are moving to primary care trusts; there are primary care trust and health authority reorganisations and trust reconfigurations. I shall visit my local ambulance station in the next few weeks and will doubtless learn of organisational changes there, too. There is a great risk that all those changes will divert attention from the delivery of front-line services.
Will the Minister support a moratorium on the introduction of any new organisational changes within the NHS to allow changes that have just been, or are about to be, implemented to bed down properly? Does she agree that NHS staff might be suffering from severe reorganisational overload?
I shall now deal with local primary care group and primary care trust set-ups. I had understood that primary care groups were supposed to be mapped on to existing communities. The London borough of Sutton is just such a community, yet it has two primary care organisations—the Sutton primary care group and the Nelson and West Merton primary care trust. All the GPs in the Sutton primary care group are based in the London borough of Sutton, whereas Nelson and West Merton primary care trust GPs are based at more than one borough.
Will the Minister explain how that benefits local residents? There are two sets of business plans and priorities, two different codes of practice and, possibly, two speeds and tiers operating in relation to primary care. Neither the local authority nor the Royal College of Nursing considers that the duplication brings benefits. They agree that primary care groups or trusts should be coterminous with local authorities—I thought that that was also the Government's view—as it is a more sensible and easier form of management.
236WH A document supplied by my local health authority states thatthose PCTs that are co-terminous with the local authority boundaries…have the potential to become a key integrative force.Presumably, that means that those that are not coterminous do not have such potential for the local health economy. That would be extremely regrettable. Even the Department of Health's website, which I checked last night, mentions primary care groups, including all general practitioners in an area.
The Government say that they are trying to get rid of postcode prescribing, and I support that aim entirely. However, the presence of two primary care organisations in the London borough of Sutton appears to be introducing a new, multi-tier health system that is not even based on postcode. Two people with the same postcode— they may even live in the same house—could receive different levels of service from their respective GPs if one has a GP in the Sutton primary care group and the other a GP in the Nelson and West Merton primary care trust.
Will the Minister explain, in writing if not immediately, why the Government have let that situation arise? I am aware of difficulties resulting from the partnership arrangements entered into by GPs in the Nelson and West Merton primary care group. Does she accept that there was some failure in the legislation that allowed such a partnership to be established?
I want to refer to the strategic direction discussion document of the Epsom and St. Helier NHS trust. I welcome the fact that the trust has described it as the equivalent of a Green Paper, which should mean that serious consultation will take place. My hon. Friend the Member for Sutton and Cheam and I will conduct our own consultation on the proposals through a public meeting early in the spring, a meeting with health professionals affected by the proposals and, I hope, a meeting with Sutton seniors forum, the local forum for old-age pensioners in the borough. I am pleased that the trust has agreed to provide speakers where relevant for those meetings.
What would be the impact on the St. Helier and Epsom hospitals if the proposals were implemented? Helpfully, the answer to that is set out on the last page of the briefing pack for Members of Parliament. There will be a small transfer of those expectant mothers likely to experience the most difficult births and of child inpatients and complex accident and emergency cases from Epsom general hospital to St. Helier hospital. The transfer of elective adult in-patients and day cases in the other direction will be much larger.
It is not appropriate for me to comment in detail now on whether the proposals are in the interests of patients. My hon. Friend the Member for Sutton and Cheam and I should conduct our public meetings and consultations to find out the views of the local community and its health professionals. There are already matters on which we would need to focus, should the proposals be implemented. One is the 24-hour ambulance shuttle service that apparently will be established to run seven days a week, 365 days a year. The service will transfer to St. Helier the small number of critical patients who, having been received at the accident and emergency ward of Epsom general hospital, cannot be dealt with there. Anything that requires a 24-hour operation, 237WH 365 days a year, will obviously be labour and cost-intensive. Guarantees would be needed that the service would be maintained, not cut, when budgets are squeezed.
I want an assurance from the Minister that the changes proposed in the discussion document will not lead irrevocably to the downgrading or closure of Epsom, St. Helier and Sutton hospitals, and the creation of one hospital to replace them. The trust accepts that the changes could be a staging post towards such a proposal, but if so, people do not want to feel that if the first step is made, the trust will have burnt its boats and that other options could not be considered. The local community does not want to be bounced into having only one hospital and it will oppose such a decision if it cannot be shown that it will deliver better-quality medical care.
Patient care must be the priority. I understand that hospitals have been given special grants to improve hospital entrances, other public areas and cleanliness. It is clear from the local government statement on Monday that the Government believe that the way forward is to earmark grants for specific projects. What efforts is the Department making to ensure that providing grants for specific projects is clinically the best thing to do? My impression from a visit to my local hospital was that if it had had a choice about using those moneys, it might not have chosen to use them to improve the public areas.
§ Dr. Jenny Tonge (Richmond Park)
I appreciate what my hon. Friend says. However, he will agree that there have been many complaints in recent years about the appearance and cleanliness of hospitals, a matter that I have raised previously. Will he ask the Minister to comment on the ever-growing lake across the main entrance to the out-patients department at St. Thomas' hospital, which seems to be getting bigger by the week?
§ Mr. Brake
If there is time, I am sure that the Minister will want to comment on the lake outside St. Thomas' hospital and on finding a solution to the problem, even if that means a bucket and a brush. My hon. Friend made two serious points, with which I agree. Cleanliness is important, but if hospitals are given large sums of money, they should have some flexibility in deciding that the best use of that money is to invest in patient care rather than tarting up the public entrances.
The merger of health authorities is an important issue. If the trust's proposed reorganisation was not enough, the health authority is now consulting about a possible merger with a neighbouring health authority or authorities. I sounded out the Royal College of Nursing about the changes; its view—before the full consultation is completed—is that a stage 2 health authority would be better than a full regional health authority. It takes that view partly because of the arrangement for the primary care trust, which covers Sutton and Merton, but also, presumably, because the health authority is supposed to provide best practice, from a regional and national perspective, and to have local knowledge. An area such as Wandsworth, Kingston, Merton, Sutton and Croydon might be too large for those involved to get to the bottom of what is happening there.
238WH Will the Minister give some guarantee that should any such merger proceed, the health authority will not be subject to a further upheaval just a few years later? It worries me when I read in the "Re-organisation of Health Authorities in South West London" consultation document issued by an independent management consultant that the current configuration exercise is to establish health authorities that have a life of three to five years. In the worst-case scenario of just three years, it would not be too long before yet another upheaval. In fact, I suspect that the authority would not have completed the merger within three years, before embarking on another one. It would not be appropriate for a health authority to go through the same trauma just three years after the previous upheaval.
The health economy in south-west London has experienced, is experiencing or is about to experience major upheaval. It is time to consolidate and sort out the basics; getting enough nurses and doctors and, improving the standards of cleanliness and the quality and quantity of food available to patients, who are often malnourished when they arrive and, according to some of my constituents, are even hungrier when they leave hospital. Given that change seems inevitable, I would like a guarantee from the Minister that the configuration adopted for primary care—or, in the future, care trusts—locally will sit comfortably with existing communities instead of cutting across them.
I would also like an assurance from the Minister that she will not allow the Merton, Sutton and Wandsworth health authority to be sidetracked into devoting much time, effort and money into a merger process with neighbouring health authorities when it should be focusing on assessing the changes that the Epsom and St. Helier trust proposes to many services, such as maternity, paediatrics and ambulance provision.
Finally, I hope that the Minister will be able to guarantee that the trust proposals will be allowed to proceed only if it can be clearly demonstrated that they are in the patients' best interests.
§ Mr. John Wilkinson (Ruislip-Northwood)
I appreciate the opportunity to speak in the debate and thank the hon. Member for Carshalton and Wallington (Mr. Brake) for introducing it. He spoke about health services in south-west London. I shall speak primarily about health services in north-west London but I shall refer also to the ever-growing process of centralisation of hospital services in the capital, which is to the detriment of overall health care, certainly in outer London. The hon. Gentleman maintained that many of the problems that afflict the health service in south-west London could be found elsewhere in the capital. This is the case in the part of rural Middlesex which I have the privilege of representing.
In an Adjournment debate on the Floor of the House on 13 November, I spoke about modernising acute hospital services in west London, with particular reference to Harefield hospital in my constituency, which is under dire threat of closure as a consequence of ill-thought-out proposals. There is within the capital a volume of change, to use the expression of the hon. Member for Carshalton and Wallington, which is deeply unsettling for personnel in the NHS and above all 239WH for patients and the general public. They feel that the service is in a constant state of flux and they have no confidence in the NHS management to manage the rate of change successfully and smoothly. Above all, they are affronted by the lack of public involvement in that process of change. It seems to them to be a thoroughly undemocratic procedure, pursued behind closed doors in an atmosphere of extreme secrecy. Health officials then spring changes on the public that they would not have wished, that they deplore and that they have little opportunity to change through the consultation process. Indeed, Mr. Cook—
§ Mr. Deputy Speaker
Order. Not for the first time today, I must remind hon. Members that when the House, in its wisdom, decided to hold proceedings in parallel fashion in this Chamber, it determined that the presiding officer should be a Deputy Speaker.
§ Mr. Wilkinson
Indeed, Mr. Deputy Speaker. I am only too delighted to give you the right nomenclature. I wrongly thought that the proceedings were as in Committee.
The rate of change to hospital services in west London has been mirrored by the number of Adjournment debates which I have had on the Floor of the House. One was on St. Vincent's hospital in Eastcote, which was virtually forced to close as a result of the Government's decision not to allow health authorities to put NHS work in so-called private hospitals—even though St. Vincent's was a medical charity and not a private hospital. There was also a debate on Mount Vernon hospital in Northwood, many of the services of which have been stripped away. It will lose the burns and plastic units to Northwick Park in the spring of next year. There were two debates on the future of Harefield hospital, on 2 December 1998 and 13 November 2000. I spoke again on 28 July 2000 about the future of this outstanding centre of excellence.
The rate of change to hospital services is so dramatic and bitterly opposed by local people that their elected representatives must spend a disproportionate amount of time concentrating on NHS issues that should be managed efficiently and effectively by the NHS itself, which it clearly is not doing. Indeed, there has been an all-out assault by the NHS on hospital services in my constituency. The assault is not yet terminated, but I hope that it will be checked by a wise decision—which I trust that the NHS will make—not to go ahead with the closure of Harefield hospital.
Vested interests are at work, which is the most malign aspect. This is evidenced by the consultation process on the document to which I referred, which was issued by the West London Partnership forum of four health authorities in west London, led by the Kensington, Chelsea and Westminster health authority. It relates to the centralisation and rationalisation of renal services, paediatric services and cardiothoracic services in west London. The exercise has been flawed by the fact that the Kensington, Chelsea and Westminster health authority is a member of the Paddington basin regeneration partnership, which would benefit from one of the most important proposals—to create a new cardiothoracic hospital in the Paddington basin.
The first meeting in the so-called consultation took place on 13 July in the Metropole hotel, Paddington. The hotel—surprise, surprise—is also part of the 240WH Paddington basin regeneration partnership, and stands to benefit from the proposals, so it is hardly impartial and objective. St. Mary's NHS trust in Paddington would also be a beneficiary of the proposals, as paediatrics would be concentrated there, and there would be a spin-off from the new cardiothoracic hospital alongside. It, too, is part of the Paddington regeneration partnership, which vitiates its independent status and damages public confidence in the process.
As I explained, Kensington, Chelsea and Westminster health authority has led the consultation proceedings, which will be wound up tonight in Imperial college, which is another potential beneficiary of what is planned. It will provide the general public with a final opportunity to have their say. However, it must be unambiguously stated that, although the public can have their say, there is no evidence that national health service officials listen to them—let alone carry their suggestions forward into implementation of new policies. This may gravely damage public confidence and lead to a total alienation of the public from the NHS management.
On 30 June, the Kensington, Chelsea and Westminster health authority asked Westminster city council for outline planning permission for the new hospital for cardiothoracic services at Paddington basin, for which it had not even issued the consultation document. It represents an intolerable presumption, pre-empting at a stroke the entire consultation process. There were two objectives behind that pre-emption. First, the health authority wanted to ensure that its planning application was in as early as possible, assuming that the consultation would be a rubber stamp and make no material difference to its proposals. Secondly, it wanted to make certain that the new Greater London Authority, which became operational on 3 July, had no role in assessing the planning implications. It was important for the health authority to circumvent the GLA's strategic planning role for the capital by getting in its application before the GLA began its operations. This was a highly unethical and unedifying little device, providing a further instance of public confidence being gravely undermined.
The new cardiothoracic hospital at Paddington basin is to be funded in part by the sale of land on the Royal Brompton and Harefield hospital sites. Any of us could tell the NHS that a far more cost-effective option would be to develop Harefield hospital, which falls within my constituency. The NHS national plan explains that the Government are rightly laying greater emphasis on improved cardiac care and that more moneys are being devoted to this admirable cause. However, Harefield might also be funded and its facilities modernised and improved. The hospital is already about the best in the world as regards care. There must be further investment in equipment, but the site and location are ideal, the personnel are committed and local people are supportive. Paddington basin is about the worst possible location for a new cardiothoracic hospital, lying in the middle of the most congested, polluted, lawless and unpleasant environment in central London. It will be much harder to find staff to work there and much more expensive to keep them.
An additional improvement to cardiothoracic services, as outlined in the document, will take place at Hammersmith hospital and will be funded by an extra 241WH £13 million. Renal hospital care is to be concentrated at that hospital, and the build-up of those services should surely be enough for Hammersmith. The £13 million should go to the improvement of Harefield hospital, and it could be done now without drastically affecting the outline plan which has been put to the public. That would be a much more sensible policy.
Even in the most favourable circumstances, the new cardiothoracic hospital in Paddington basin will not be operational until 2006. Let us use the moneys from Hammersmith hospital and the moneys being made available under the NHS plan for cardiac medicine to improve Harefield hospital. In that way, an outstanding centre of excellence, which has done more heart transplants than any hospital in the world, can continue to operate to the benefit of all.
The final point is that NHS services in London are often planned centrally and take no account of the knock-on effect outside the metropolitan area. Harefield hospital is a case in point. It takes patients from all over the country and from abroad. Only 10 per cent. of the hospital's patients come from the borough of Hillingdon, where it is located. For it to be treated merely as part of the London NHS service is parochial and inadequate. The four health authorities concerned ought to have involved neighbouring health authorities much more widely, but they made no effort to do so. It is a national decision, and it should not be taken on a London basis.
I share the anxieties of the hon. Member for Carshalton and Wallington for south-west London, but drastic changes are needed also in north-west London. A good place to start would be to forgo the option of closing Harefield hospital. The hospital has had an outstanding past and it has a great future. People believe in it, and it should be allowed to carry on successfully.
§ Dr. Jenny Tonge (Richmond Park)
I congratulate my hon. Friend the Member for Carshalton and Wallington (Mr. Brake) on bringing this subject to the attention of the House. The Minister has about 15 minutes to speak about the health service in London. She has my sympathy, because it would take about a week to do that properly.
I want to speak not only about the problems, but about the good features of the London ambulance service NHS trust. Way back in the last century, I was a casualty officer at University college hospital. I was there for more than a year and came to know the London ambulance service, as it was then, very well. Last weekend, I went on a trip down memory lane. I spent Saturday night with the ambulance service in Richmond, and went out the ambulance men on their calls.
I am delighted to report that nothing much has changed. Medicine and emergency treatments may have changed, but members of the ambulance staff have the same extraordinary character; a combination of intelligence, quick thinking, intense patience, hard work and the ability to laugh off the most extraordinary difficulties. I hope that the House shares my admiration for them. About 700,000 calls per year are made to the 242WH ambulance service in London, and the ambulance staff answer them in about 350 vehicles. I cannot speak too warmly of them.
I was pleased also to hear the tremendously warm words that the ambulance crews had for the newly appointed chief executive, Peter Bradley. He has come up through the ambulance service but, even in the exalted position of chief executive, he finds time every week or two to wear a reflector jacket and act as a crew member somewhere in London. He wants to know the problems and difficulties that are being encountered by the ambulance service. That is some chief executive. I commend his activities to all chief executives in the health service, many of whom are out of touch.
The ambulance staff are being asked to do the most extraordinary things, but I am glad to say that standards in London are extremely high. That is due largely to Dr. Fionna Moore, the medical director of the London ambulance service, who trains and retrains the ambulance crews and organises seminars and teaching sessions for them, so that they can perform ever more difficult procedures and provide ever more advanced medical treatments to their patients on the way to hospital.
§ Mr. Philip Hammond (Runnymede and Weybridge)
I am enjoying the hon. Lady's description of the marvellous work done by the London ambulance service, but will she confirm for the record that it is bottom of the national league for response times?
§ Dr. Tonge
I am coming to that. Response times are important, but it is also important to point out first what is excellent about the service. I hope that the hon. Gentleman agrees.
The quality of the service in London is good, but there are no national standards. It depends entirely on the medical director; another director may not be as good. The Minister needs to address that problem and ensure that there are national standards and protocols for ambulance services, so that the quality of the London ambulance service does not slip back if it has a change of staff. We have a helicopter service in London, albeit a scanty one. The police or ambulance service can summon a helicopter if they are in an extremely serious hole and need urgent help from the doctor on board. Helicopters are good, but there are far too few of them.
The hon. Member for Runnymede and Weybridge (Mr. Hammond) mentioned response times. An ambulance should respond to a call inside eight minutes. As we all know, however, the London ambulance service's response rate is appalling. Its target was to attend 55 per cent. of calls inside eight minutes, but it achieved only 32 per cent. To someone who goes out with an ambulance, as I did, it is obvious that a vehicle travelling along the ground—albeit with flashing blue lights and a siren—simply cannot get through the London traffic. The problems with public transport have made it even worse. A journey in my car last week between Westminster and Kew, where I live, took two and a quarter hours. An ambulance making the same journey—a distance of less than six miles—will not make it in less than half an hour, even with its blue lights flashing. The problem is extraordinary and must be addressed.
§ Mr. Wilkinson
The hon. Lady is making an exceedingly important point about traffic. With the 243WH benefit of her experiences in the ambulance and in her car, does she agree that locating a premier heart hospital—which will take the most critical cardiac cases, involving people teetering on the edge of death—in the centre of London is absolute madness? Would it not be much better to keep the hospital at Harefield, which has easy access—because it is close to motorways and open country—and is a far more rational location?
§ Dr. Tonge
At times, I have been slightly irritated by the hon. Gentleman's constant advocacy for Harefield hospital, but his points in this debate have made me think. I am listening to his arguments and I entirely agree with him. The more I think about concentrating all our high-powered emergency services in the centre of London, the dafter it seems. The hon. Gentleman has done much to change my mind.
The problem is difficult to solve and is compounded by a shortage of ambulances. In Richmond, for instance, one ambulance is on duty and another is shared with surrounding areas such as Hounslow and Chiswick. Richmond does not have a spare ambulance. If one of them breaks down, that's it folks—unless a spare stand-by ambulance from another area can be used. That is a serious problem.
§ Dr. Tonge
Yes, I was going to come to that. The call-outs that I experienced and was told about while I was working with the ambulance men ranged from the most trivial to the most serious and appalling cases. The 999 calls cannot be refused, although the switchboard tries to prioritise them. There can be a bit of a queue for an ambulance. On Saturday evening, for example, our ambulance service—fully equipped with defibrillators, paramedics and goodness knows what else—was called out by a woman who had splashed vinegar in her eye. An ambulance had to go out to that call, which seems an extraordinary waste of resources. I do not know how may hundreds of pounds that must have cost.
My hon. Friend the member for Carshalton and Wallington is quite right. We could use other resources for the non-urgent cases. I would ask the Minister to address the matter of obviously minor injuries. We trust NHS Direct to make judgments about whether a patient should go to hospital or the local pharmacist and we could do the same with the ambulance service. If NHS Direct is to be allowed to call ambulances in the future if it considers a condition serious, could not the two services liaise in some way so that the ambulance service can refer a patient with vinegar in her eye back to NHS Direct for advice? We need to think this out so that we do not use valuable teams to go out to trivial injuries. The other problem on a Saturday night was the drunks.
§ Mr. Hammond
Will the hon. Lady clarify whether she is arguing for the routing of 999 emergency calls through NHS Direct?
§ Dr. Tonge
I am asking for it to be looked at. I am not being dogmatic. If we can allow NHS Direct nurses to 244WH call ambulances, why can we not allow what turn out to be trivial cases—although they may not seem so to the person involved—to be referred back to NHS Direct when 999 is called unnecessarily? I would like to have a discussion and to work through what would happen if we did that.
I come back to the problem of the drunks, who are often an absolute pest. They occupy hours and hours of ambulance and casualty time for the sake of a couple of stitches on a chin, as I saw at the weekend. It was nonsense that hundreds of pounds were spent on someone who had fallen down because he was drunk and had a small cut on his chin. We must rethink the service if we are to use it more effectively.
One of the biggest problems for the London ambulance service is keeping staff. The average ambulance man with full paramedical training earns about £20,000 a year. They start as trainees at around £12,000 and work up to £18,000, but with overtime they can get £20,000. These are people who do cardiopulmonary resuscitation, set up intravenous drips and make judgments as to whether to call a crack team in the helicopter service; they earn, if they are lucky, £20,000. As long as they are paramedics, they stay at that level. There is no increment for years of service, apart from inflation. That is another outrage. Ambulance men are the lynchpin of the emergency service and they should be properly rewarded.
I discovered that eight ambulance men had recently left the Chiswick station in south-west London. They are not leaving the ambulance service; they are just moving out of London. If one moved right out into the countryside, one could exist on that sort of pay and find somewhere decent to live. However, people cannot live on that pay in the London area. Three are leaving Richmond. One told me that he was going to the west country where, instead of his cramped, two-bedroomed rented flat, he will be able to afford a mortgage and buy a three-bedroomed house with a nice garden. What chance is there of retaining those valuable staff if we do not tackle the problem?
I was asked to inquire as to what had happened to the help with mortgages scheme that the Government trumpeted in the spring. Health service staff were to be allowed interest-free mortgages, but ambulance men in London do not seem to have heard anything about the scheme. The ambulance service is desperately short of staff; it is more than 400 down on its requirements. Although the Government have in their wisdom told the service that it can have more staff and that more funding is available, it is necessary to find and recruit the people. The same is true of nursing and many other professions allied to medicine in the London area. The problem is a serious one and needs to be taken seriously.
The people who work in the service are denigrated because they do not achieve their targets, but they provide care of extraordinarily high quality to the patients with whom they deal. We should always remember that. The health service should cease to worry so much about targets and should pay more attention to the quality of care.
§ Mr. John Randall (Uxbridge)
I apologise to you, Mr. Deputy Speaker, and to the hon. Member for Carshalton and Wallington (Mr. Brake), for missing his 245WH first few remarks. I congratulate him on obtaining the debate, which allows us another opportunity to discuss our concerns.
I support my hon. Friend the Member for Ruislip-Northwood (Mr. Wilkinson) in his remarks about the removal of services from our borough, and the potential threat to Harefield hospital. Unlike the hon. Member for Richmond Park (Dr. Tonge), I have never been irritated by my hon. Friend's advocacy of his constituency interest; such advocacy is probably the highest calling that anyone in this place can have. The people of Harefield and the Harefield hospital are lucky to have such a doughty crusader to speak for them.
Local Members of Parliament stand shoulder to shoulder on this issue—and I include the hon. Member for Hayes and Harlington (Mr. McDonnell) in that. Only last week, we had a third joint meeting of what I suppose these days is called the health economy in Hillingdon. I am not a great one for modern phrases, but I suppose that that sums up the matter quite well. At each of those meetings, the constant theme is the lack of confidence in consultation.
Yesterday I was here, listening to an interesting debate instigated by my hon. Friend the Member for Eddisbury (Mr. O'Brien) about community health councils. There was a strong impression that consultation on that matter had been along the lines of announcing, "There will be consultation about the future of community health councils, but they will be abolished." The same theme has been constant in my constituency and others. Consultation affecting Harefield and Mount Vernon hospitals has been of the same kind. Limited consultation is arranged, but everyone knows what the outcome will be. That does nothing to encourage belief in what the national health service is providing locally.
Of course, local provision is not what we are considering with respect to Harefield hospital. Harefield carries out 170 operations a year, of which 62 are heart and lung transplants. In total, 2,300 successful heart transplants have been carried out, which is a world record. Harefield is a European training centre for cardiologists. Some 60 countries send doctors there to be trained, who then return to their countries with new skills learned at Harefield. Some 95 health authorities purchase health services from Harefield hospital, and that covers roughly 9,500 episodes a year.
As the hon. Member for Richmond Park said, my hon. Friend the Member for Ruislip-Northwood has, of necessity, raised the issue many times, but it is always worth repeating such things. More than half of patients come from west, east and north Hertfordshire, Hillingdon, Harrow, Bedfordshire and Buckinghamshire, so access is very important. The hon. Member for Richmond Park mentioned the problem of access to the proposed complex at Paddington basin, with regard not only to gridlocking on the roads, but the public transport system. Like many other London Members of Parliament, I often use the underground, and the system is not at its best. For patients, and especially for visitors who must make several trips to the hospital, the state of underground and road systems will lead to further stress.
246WH Although I am a lay person in these matters, there is a point which strikes me as obvious. Harefield is a marvellous location for care following the sort of surgery that we are discussing. Anybody who has been there will realise why the site was chosen. It is a superb location for recuperation. I cannot believe that the Paddington complex, even with its wonderful new buildings, will provide that same natural environment for recuperation; that is common sense. Many patients who come for major surgery come from a long distance away. Accommodation costs will be much higher in the centre of London. Many such matters have been brought before the House before, but we have reached a crucial period.
Costs are often mentioned. I found it striking that, according to figures supplied by the West London Partnership, Harefield needs only £20 million to bring it up to a minimum viable standard, whereas the new complex will cost£132 million. I am a simple person, but I cannot help feeling that the difference between those two amounts could be better used than for providing a new hospital when we already have a superb hospital that needs only bringing up to standard.
A report commissioned by the NHS Executive in 1999 and carried out by York university found that bigger hospitals are not necessarily better in terms of efficiency or quality of care. The report concluded that, overall, there was no compelling reason to believe that further concentration of hospital services would result in improved efficiency or automatic improvements in the quality of clinical outcomes. I am a great believer in the idea that small is beautiful. My constituents want to feel that their national health services are a part of the community, and the insistence on centralisation flies in the face of what people want.
§ Dr. Tonge
Does the hon. Gentleman agree that a lot of that change is being driven by the general public's need for clinical excellence and expertise? The royal colleges, which are in charge of these matters and in charge of training, insist that hospitals should be big so that there is available the necessary expertise for the training of junior staff.
§ Mr. Randall
We all want clinical excellence, but I am not entirely sure that big always means the best. I concede, however, that I am a lay person and that the hon. Lady has great experience in such matters.
I should like the Minister to respond to all the issues that I have raised, although I am beginning to become a realist in this place. I am sure that all Members of Parliament hear horror stories about the national health service. In the past few weeks, I have been contacted about what has gone on in the Hillingdon hospital and elsewhere, and such matters must be dealt with. Occasionally, however, people write about the wonderful care that they have received, so we must be careful not to concentrate on the bad side. I pay tribute to those who work in the national health service and who have to work under extreme pressure for various reasons, many of which I cannot lay at the Government's door. Some I can, but I shall leave that for another time.
§ Mr. Paul Burstow (Sutton and Cheam)
I congratulate my hon. Friend the Member for Carshalton and Wallington (Mr. Brake) on securing the debate and on giving us the opportunity to discuss the health service, which is one of the most important issues that face us all. He referred to the massive change that the NHS is experiencing throughout the country, particularly in south-west London.
I must resist the temptation of becoming embroiled in my constituency interests, but the debate has rightly drawn attention to the worry that perhaps too much management time is being invested in reorganisation, rather than in the key issues of delivering better health outcomes for the population of London. Reorganisation, for its own sake, is a distraction; a worry that is echoed by some managers. I hope that there will be less reorganisation and more focus on delivering much of the health agenda for which the Government have been calling and many of us support.
Hon. Members have highlighted another part of London. My hon. Friend the Member for Carshalton and Wallington referred to south-west London, and the hon. Members for Ruislip-Northwood (Mr. Wilkinson) and for Uxbridge (Mr. Randall) rightly drew attention to the health service in north-west London. They spoke of their experience of the process surrounding decisions affecting Harefield hospital. Both hon. Gentlemen were right to highlight the lack of accountability and transparency in the NHS decision-making process and the fact that, all too often, the formal consultation stage, when it is reached, comes far too late to have a serious effect on that process.
The hon. Member for Uxbridge made the important point that when we debate the health service, it is inevitable that we focus on those matters that are not entirely right. I make no apology for the fact that I may do that in my speech. However, he was right, as was my hon. Friend the Member for Richmond Park (Dr. Tonge), to highlight and praise much of the dedicated work of NHS personnel in all positions.
The debate is timely. We must recognise that we are on the verge of the busiest time of the year for our health and social care systems. It is a time of great stress and strain for all care staff, when the health and social care systems are tested to their limits. Signs are already emerging that this year's winter pressures will be every bit as intense as last year's. All it will take is another flu outbreak or a major incident to tip our health and social care systems over the edge. I wish to explore why the system is still vulnerable. Some of that vulnerability is a result of the previous Government's failure over a decade or more to invest in NHS and social care capacity. There are fewer nurses, doctors and beds.
Three factors will be crucial to managing winter pressure: the looming bed crisis in the private nursing home sector; the shortage of NHS beds; and the poor performance of the London ambulance service. The most recent annual returns state that London has lost 2,491 nursing home beds. The trend and the analysts point to an acceleration in home closures during the past year; something that will continue. About 50 per cent. of all admissions to nursing homes take place direct from hospital. Nursing home beds are therefore a critical part of the bed-blocking equation. Fewer nursing home beds means more delayed discharges.
248WH Why are there fewer nursing home beds? The answer is simple; the cost of running care homes is increasing much faster than the level of state funding. A care home worker can earn more stacking shelves in Safeway than he or she can earn caring for a frail, elderly person, and that is even before one takes account of the extra costs of recruiting and retaining staff in London.
This year, the fees for state-funded nursing home places increased by only 2 per cent. On top of the rise in costs, many people in that sector feel uncertain about the future. The way in which the Government handled the new care standards for homes has undoubtedly done serious long-term damage to confidence in the market, which is at an all-time low. Costs are rising. People will not want to invest in the market; it gives no return at present. However, there is a certain return, in that the land is worth more with flats or houses on it than nursing home residents.
Problems in the nursing home sector are compounded by bed and staff shortages in the NHS. About a third of all nursing vacancies are in London. It does not pay to be a nurse in London. The Office for National Statistics says that the average wage in London is now £28,812. What pay is on offer for nurses in London? The Nursing Times advertises a qualified D grade staff nurse post with a starting salary of £17,257, including London weighting. That is £11,000 less than average London earnings. Even highly qualified staff are paid less than the London average. For example, the salary of a grade G ward sister to run a specialist ward in London is advertised as £23,962. It is hardly surprising that London has such a chronic nursing shortage, given that the pay is so out of touch with market conditions.
Depending on which newspapers one reads or to whom one talks, the figures vary, but it has been stated that there will be an extra 41 intensive care beds in London this winter. Is that figure accurate? Yesterday, my office contacted the NHS regional office to find out whether London will receive those extra beds and the staff to support them. Despite repeated questioning, that office would not comment on the plans for intensive care beds. It refused to comment on the number of beds, where they will be and whether they will be fully staffed and up and running by the planned date of 1 December. How many extra beds will be available to the NHS in London this winter compared with last winter? How many staff will be needed to support those beds? How many of those staff are in post today or will be in post on Friday, 1 December? Will those extra beds be fully staffed and operational by then?
§ Mr. Hammond
I want to clarify the term "intensive care beds". The report that drew attention to the 41 beds refers to "critical care beds". Mention has been made of high-dependency beds, intensive care beds and critical care beds. Are not the Government simply playing a game with terminology?
§ Mr. Burstow
The hon. Gentleman makes a fair point and one that I am sure he will develop later. Different reports that use different terminology cause the confusion. I hope that the Minister will be able to shed light on such issues.
Without the extra beds and staff, London will be facing another winter of trolley waits and ambulances ferrying sick people around accident and emergency 249WH departments for want of a bed. My hon. Friend the Member for Richmond Park referred to the London ambulance service. She rightly paid tribute to the dedication of ambulance crews and touched on the difficulties that crews face in respect of alcohol abuse, which affects the efficiency of the NHS and has a physical impact on ambulance crews. The numbers of assaults due to people being intoxicated is an unacceptable factor in the work of those crews.
Despite the dedication of the crews, the performance of the London ambulance service is the worst in the country when compared to other urban ambulance services. If one dials 999 in London, three times out of five the ambulance will take more than eight minutes to arrive. The best performance is in the west midlands, where in three out of five cases the ambulance arrives within eight minutes. Things in London have got worse and not better over the past year, as the ambulance service moves away from the Government target of a 55 per cent. response rate for 999 calls. A host of factors combine to make London the bottom of the league in that respect.
I hope the Minister will comment on traffic, which is a key issue. What assessment have the Government made of the impact of the extra traffic on our roads this winter due to the crisis in the railway system and the safety work that is being done? That extra traffic makes it even more difficult to achieve response times. What contingency plans have been made to ensure that there are extra ambulances to guarantee some attempt to achieve those times?
In addition to the delays on the roads, delays are happening in hospitals. More than 1,000 hours a month are wasted as ambulance crews are forced to wait for patients to be admitted, which means that fewer ambulances are available to respond to 999 calls. That figure is based on average turnaround times collected in April and June. Does the Minister agree that turnaround times are likely to rise during the winter? What steps are being taken to prevent a further fall in attendance times as a result of the time spent waiting for a bed to become available? Another factor is that many of the dedicated professionals leave the service because they cannot afford to live and work in London.
A failure to recognise the collapsing confidence in the nursing home sector and the bed shortages that it is causing will exacerbate bed blocking in the NHS this winter. The failure to plan for increased capacity in the NHS for over a decade or more further exacerbates the pressures caused by bed blocking. The result is care gridlock in our system; life or death delays in 999 calls and more trolley waits in overstretched accident and emergency departments. Will the Minister lift the veil on the issue of how many beds will be available, whether they will be new beds and whether they will be fully staffed from 1 December?
§ 12.7 pm
§ Mr. Philip Hammond (Runnymede and Weybridge)
I, too, congratulate the hon. Member for Carshalton and Wallington (Mr. Brake) on securing the debate. Our previous debate on London health services was on 14 June. Following the implementation of the Ternberg 250WH report, it is right that the House should regularly review progress in the development of those services. I am disappointed only in that not one London Labour Member of Parliament has bothered to attend the debate, despite the political stranglehold that the Labour party has on the capital. I hope that the House continues to monitor London health services, taking into consideration what matters to patients—the outcomes—and not the input made to the service by the Government, although that is what the Government would prefer to discuss.
The hon. Member for Carshalton and Wallington said that in south-west London, we see a microcosm of the problems affecting the health service in London. It is also fair to say that, despite the special problems facing the service in London, the city represents a microcosm of the problems facing the NHS throughout the country.
Since our previous debate on the NHS in this Chamber, the Government have released their NHS national plan—a 10-year plan delivered after three years in office by the party that told us that we had 24 hours to save the NHS. With the 10-year plan in front of us, we can see the gap between Government rhetoric and the reality experienced by the people of London in their daily contact with health services.
The NHS in London has a revenue budget of about £5 billion and employs about 140,000 staff, so it represents a significant part of the NHS nationally. As we move towards the annual winter pressures, the media, which is largely based in London, will focus on what happens in the NHS in London. That will put London's health services under the spotlight—and under a tremendous amount of political pressure as well.
Among the national issues that impact on London in particular—some of which have already been mentioned by hon. Members—staffing is key. Nursing numbers in many London trusts are 25 per cent. below establishment numbers, which constitutes the worst shortage in the country. On this morning's "Today" programme, the Minister valiantly defended the Government's record against comments by the Royal College of Midwives about the midwifery crisis in London. Like me, she will have heard a midwife from King's college hospital say that its maternity department had to close twice in a week. That was the first time in 13 years that it had to refuse admissions.
In respect of the reduction of junior doctors' hours, five of the 10 worst non-complying trusts are London trusts. Even at the level of qualified surgeons, there are great difficulties in recruiting and retaining staff in London. The national service framework for coronary heart disease requires that, by 31 March 2001, no patient will wait longer than 12 months for cardiac surgery. Will the Minister concede that that requirement will not be deliverable in London, and that the Government are exacerbating the problem and alienating senior cardiac registrars by threatening to bar them from private practice when they become consultants?
I should not leave this issue without mentioning the problem of ancillary staff. Even when it is possible to find nurses from the Phillipines or Spain, or doctors from Germany or Finland, hospitals often find it difficult to clean wards, move patients around and deliver food to them. The pressure to find ancillary staff is worsening all the time.
251WH Like other hon. Members, I pay tribute to the tremendous work undertaken by London NHS staff. They work under great pressure, and often for little thanks. Many face daily abuse and violence, and morale is at rock-bottom. That is made worse, I am afraid to say, by the brick bats that Ministers—and the Prime Minister himself—regularly aim at doctors in particular.
As the hon. Member for Sutton and Cheam (Mr. Burstow) said, another problem is bed blocking, although I fear that he may have understated it. He mentioned a figure of some 2,400 beds a year, based on recent statistics. However, according to figures that I collected yesterday for Kingston upon Thames—the smallest London borough—there has been a net loss of 300 beds in the residential and nursing care sector since 1 April this year. That suggests a meltdown and, as the hon. Member for Sutton and Cheam said, it leads directly to the bed-blocking problems that will undermine the Government's careful preparations for this year's winter crisis.
§ Dr. Tonge
The previous Government closed Queen Mary's hospital in Roehampton without making any provision for the extra beds that were consequently required. Does the hon. Gentleman agree that that has contributed to the intense problems in Kingston and, indeed, Richmond, which is part of my constituency?
§ Mr. Hammond
The hon. Lady is addressing a slightly different point. Bed blocking is created by the inability to discharge patients who have completed their clinical care and need continuing social care. As she well knows—if she does not, her hon. Friend the Member for Sutton and Cheam does—that is a major problem that undermines the Government's attempts to deal with this winter's NHS crisis.
On 23 November, just one intensive care bed was available in London. The hon. Member for Sutton and Cheam mentioned that 41 additional beds were promised, but no one has been able to confirm whether they are intensive care beds. The number of outpatients in London who wait longer than 13 weeks is on the rise. One major London trust told me yesterday that orthopaedic outpatients are waiting more than one year to see a consultant. In London, the number of operations cancelled on the day is rising.
The suspended list, comprising of patients who no longer appear on the waiting list because they have been suspended, is a scandalous device that is widely used in London and elsewhere to reduce waiting lists and achieve targets. How many patients in London are now on the suspended list, following the scandal at King George V hospital in Ilford more than a year ago?
One in four of the longest accident and emergency waits in the country occurs in London. Waits of more than two hours are increasing—a fact that is regularly mentioned, no doubt much to the annoyance of Ministers, by London community health councils in their casualty watch reports. For example, on 21 August, Tower Hamlets community health council reported that a 66-year-old patient with abdominal pain waited on a trolley for 19 hours after the decision to admit him. Is that why the Government are so anxious to abolish community health councils? Can the Minister 252WH look hon. Members in the eye and tell them that she expects the Government's new patient advocates, who are employed by their NHS trusts, to sendunsolicited—to Members of Parliament the kind of damning information that we regularly receive from CHCs?
It is easy to focus on the big headline issues that affect London's hospitals, but we must never forget that alongside the great centres of excellence are some of the worst performing and worst delivered primary health care services. For the sake of the NHS in London, I appeal to the Minister to ensure that when the Government address the special problems that London faces—such as the inexorable rise in TB cases, falling levels of vaccination, rising teenage pregnancies and the above-average rate of adult male mental health problems—they do not forget the requirements of ordinary people who do not have high-profile needs, belong to a specially targeted group or have Government ring-fenced money directed at them. The future of the NHS in London depends on maintaining a consensus based on the understanding that the needs of ordinary people can be met by the service; that after all the high-profile and glamorous work has been done, enough money will be left to deliver proper primary and community health care services.
Will the Minister tell the people of London how she can square the Secretary of State's rhetoric two weeks ago"when he announced a doubling of the ring-fenced money to address inequalities"with the fact that Camden and Islington will be the only London boroughs to receive any of that extra money? London will receive only £1.3 million of the £130 million that was announced. Can she explain to the people of Newham why, given that the Government are supposedly addressing inequalities in health care, a place such as Newham will receive no additional money whatsoever under the initiative announced by the Secretary of State? In reality, that initiative is about distributing money away from London to places further north.
This has been a useful and interesting debate, and I look forward to the Minister's response. I hope that she will deal with some of the specific points that I and other hon. Members have made.
§ The Minister for Public Health (Yvette Cooper)
I add my congratulations to the hon. Member for Carshalton and Wallington (Mr. Brake) on securing the debate. We last debated the subject during the consultation process on the NHS plan, so this is a timely opportunity to discuss how the plan will take forward proposals for the NHS in London and the implications of that.
The NHS faces particular challenges in London, a diverse city with a population of more than 7 million. An additional 2 million people come to the capital each day for leisure purposes and another 1 million non-Londoners commute daily to work in the city. That inevitably places great pressure on the national health service. London's greater mix of ethnic groups and sharper extremes of wealth and poverty—with high unemployment, low pay, poor housing, crime and environmental pollution in some areas—all contribute to the problem.
The NHS employs more than 140,000 people in London alone and is the largest employer. It is larger by far than any company and in most boroughs it is among 253WH the largest employers. I join the tributes made by hon. Members today to the immense contribution made by hard-working NHS staff throughout the city and the difference that they make to patients' care and patients' lives.
I shall respond to some of the general points that have been raised, especially those in the context of the NHS plan, but I shall try first to deal with some of the specific issues.
The hon. Member for Carshalton and Wallington referred to Orchard Hill, where the health authority is in discussion with the local community following the judicial review. He also referred to proposals concerning primary care groups and trusts and changes to health authorities. He knows that I am limited in what I, as a Minister, can say because any proposals for change would have to go through extensive public consultation and the proposals have not been announced. We prefer to encourage coterminosity because it can make joint working, especially with local government, considerably easier. However, there must be flexibility to cope with local circumstances and communities.
The NHS plan covers fundamental change not in institutions and restructuring, but in ways of working in institutions and in partnership among institutions. Reconfiguration sometimes contributes to that, but sometimes it is a distraction. We expect health authorities and institutions throughout the country to make delivery of the NHS plan a priority and to ensure that any changes are in the context of delivering better care for patients. The hon. Member for Carshalton and Wallington knows that I cannot comment in detail on the Epsom and St. Helier NHS trust because the consultation is only just concluding and proposals may be referred to Ministers. However, it was helpful to hear his views.
It was also helpful to hear the views of the hon. Member for Ruislip-Northwood (Mr. Wilkinson). As he said, consultation is under way and as proposals may be referred to Ministers later, he will know that I cannot comment at this stage. However, I can tell him that we shall keep benefits for patients at the top of our criteria for assessing any proposals for change.
The hon. Member for Richmond Park (Dr. Tonge) referred to a lake at St. Thomas' hospital. I visited the hospital less than a month ago and I did not see a lake, but I shall ensure that her comments about it are passed on. She also paid tribute to the hard work of the London ambulance service and I join her in that. The target response for ambulances throughout the country is eight minutes. The London ambulance service's aim is to reach 55 per cent. of patients within eight minutes by the end of March next year.
There are additional problems in a busy capital city, but the service has made considerable progress. In the past seven years, the demands on the service have almost doubled and, in the same period, the number of responses meeting the eight-minute target has increased from 12 per cent. in 1993 to 41 per cent. today. Clearly that improvement needs to continue and the amount of medical, support and emergency services that we can provide through the ambulance service is supported by the NHS plan. I shall write to the hon. Lady about the 254WH issues that she raised concerning links between the ambulance services and NHS Direct. We have invested an extra —21 million across the country to improve ambulance response times, and to meet the national service framework in respect of coronary heart disease.
The hon. Members for Runnymede and Weybridge (Mr. Hammond) and for Sutton and Cheam (Mr. Burstow) raised various issues concerning London that I shall try to address as I cover some more general points. We are setting out a huge programme of implementation for the NHS plan, which includes setting up a modernisation board with task forces in many areas to oversee the programme. I am pleased that a London modernisation board has been set up, and I am delighted that it includes clinicians and managers from the NHS, partner organisations and patient and user representatives. Clearly, to implement the NHS plan, we need an effective partnership across the city.
Part of the story of implementing the NHS plan and addressing many of the concerns raised by hon. Members concerns extra resources for the NHS in London. This year, there has been already a significant increase in resources for the NHS in London. Next year, there will be an above average increase of 8.9 per cent., including extra help to tackle both inequalities and the cost-of-living supplement. The cost of living is a particular issue in respect of recruitment pressures within the city. For the first time, we have given health authorities a guaranteed minimum level of funding not only for one year, but for future years.
§ Mr. Hammond
The Secretary of State announced a —70 million increase in the ring-fenced inequalities fund. Why has only —1.3 million of that money gone to London, a city with two thirds of the most deprived local authority wards in the country?
§ Yvette Cooper
I have been searching through my papers for detailed figures about the allocations, and I shall write to the hon. Gentleman on that point. Clearly, there is an inequalities issue in London; that is why we have health action zones in Hackney, Lambeth, Southwark and Lewisham. We must tackle inequalities right across the city. That is why, for example, we are examining both the causes and prevention of health inequalities, which the Conservative Party fundamentally failed to do in 18 years in office. Inequalities are at the top of the Government's agenda.
Returning to the issue of extra money, there will be a —493 million increase for London next year, which will take its total allocation to more than —6 billion. Compared with an average real increase of 3 per cent. in previous years, an increase of more than 6 per cent. over several years constitutes a sustained increase.
The hon. Member for Runnymede and Weybridge was happy to list a series of complaints about the NHS, but I am interested to know how he expects them to be addressed. We have set out a clear programme for investment and reform, and I am unsure whether he is calling for resources in addition to that extra investment, or whether he intends to abandon his proposed subsidy for private health insurance to make up the shortfall in the investment that would be needed to match our proposals. Over the next few years, our 255WH capital investment plans include —3.5 billion to be invested in primary, community, mental health and hospital settings.
§ Mr. Burstow
Will the Minister write to me to answer the questions about intensive care beds, so that we can have those answers on the record?
§ Yvette Cooper
I shall certainly write to the hon. Gentleman. I was about to discuss our preparations for winter, with which I shall try to deal rapidly. We have already made available more than —34 million of additional funds for the winter in London, and we shall set out the exact proposals on critical care beds and acute beds. I understand that plans are in place for an extra 40 critical care beds and an extra 400 acute beds, compared with last winter. We shall set out further details in due course about the extra capacity in the capital this winter.
Discussions are continuing about further investment this winter, which is needed. We also need to reform the way in which things happen. Many excellent proposals have been put into operation in London already, including the innovative cancer collaboratives, which change how NHS care is provided. A huge number of other proposals will come on-stream as a result of the NHS plan, which should make a substantial difference to the care of patients in the capital city.