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House of Commons

Tuesday 24 January 1989

The House met at half-past Two o'clock


[Mr. Speaker-- in the Chair ]


British Railways (Penalty Fares) Bill

[Lords] Order for Second Reading read.

To be read a Second time on Thursday 26 January.

Contingencies Fund 1987-88


That there be laid before the House accounts of the Contingencies Fund, 1987-88, showing the receipts and payments in connection with the Fund in the year ended 31st March 1988, and the distribution of the capital of the Fund at the commencement and close of the year ; with the Report of the Comptroller and Auditor General thereon.-- [Mr. Norman Lamont.]

Oral Answers to Questions


General Practice (Cash Limits)

1. Mr. Hayes : To ask the Secretary of State for Health what plans he has to cash-limit general practice ; and if he will make a statement.

The Secretary of State for Health (Mr. Kenneth Clarke) : My objective is to achieve a good quality service for patients and value for money in general practice, as in the rest of the National Health Service. My hon. Friend may wish to await our proposals for the whole of the NHS which will be published shortly.

Mr. Hayes : As I am sure that my right hon. and learned Friend appreciates the importance of general practitioners giving value for money to the patient and the taxpayer, will he take into account that they also act as a helpful safeguard--a safety valve--for a cash-limited hospital sector, which makes it important that there be the absolute minimum of Treasury interference?

Mr. Clarke : General practice is the key to a great deal of the British Health Service's success. The general practitioner is the first person to whom a patient looks for advice for himself and his family. The general practitioner is the gatekeeper to the rest of the Health Service, deciding on referrals to the most suitable part of the service. I certainly accept the value of general practice and I am sure that our proposals, when published, will underline its crucial role and seek to support general practitioners in carrying it out.

Ms. Harman : How does the Secretary of State answer patients' justifiable fears that when general practitioners

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are kept to fixed budgets they will limit patient care so as to keep within the budget? Will not doctors give treatment to suit the budget rather than treatment that suits the patient, and what happens if the money runs out?

Mr. Clarke : At the moment, I am telling people with hypothetical fears about hypothetical proposals that they should wait for our full proposals to be published, together with the supporting arguments, which I am sure will set the hon. Lady's fears at rest.

Mr. Ian Bruce : Does my right hon. and learned Friend agree that the low percentage of GDP that we spend on our excellent Health Service is a measure of the value that we receive from general practitioners and their cost-effectiveness in delivering health care? Can he assure me that after the review of the NHS the general practitioners will play a leading role in delivering services to their patients?

Mr. Clarke : I agree with my hon. Friend's first point and I shall try to match up to his hopes on the second point. We have a pretty cost- effective service. One reason for that is the fact that general practitioners refer people, thus making the best use of the hospital service. I much prefer our system to that which prevail in other countries, where patients are expected to have individual specialists for whatever complaint they think that they have, and thus go to the part of the service that they judge best, without professional advice.

Junior Doctors

2. Ms. Armstrong : To ask the Secretary of State for Health what information he collects from district health authorities concerning the contracted hours of work of junior hospital doctors ; and from what date such information has been collected.

The Minister of State, Department of Health (Mr. David Mellor) : Information has been collected each year since 1976 on the number of contracted hours of duty for each junior hospital doctor in England and Wales. Contracted hours comprise hours of work and hours on call. They fell from an average of 91.3 hours in 1976 to 85.7 hours in 1986.

Ms. Armstrong : In the light of the grave concerns that junior hospital doctors are expressing about their ability properly to carry out their role, what reassurance can the Minister give to patients that their lives and future are safe in those hands?

Mr. Mellor : The hours that junior doctors work are determined by the heads of their clinical teams. A key part of the judgment of those who determine those hours is to ensure that the doctor carrying out the duties is capable of so doing. However, the Government are dissatisfied with the situation in which a significant minority of junior hospital doctors are expected to work and to be on call for far too many hours. Last June my predecessor asked each district to set up a working party, consisting largely of doctors, to eradicate any scheduling worse than one in three. We are in the middle of that exercise, but the evidence that we are receiving from the regional health authorities suggests that further reductions are being made as a result of that initiative. The working party is on course to report fully by the end of September.

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Dame Jill Knight : Can my hon. and learned Friend confirm that not all specialties involve long hours for junior doctors in hospitals? Some are not really very bad. Secondly, is he aware that it has been put to me by professional concerns that because doctors' qualifications often depend on the hours worked in certain specialties, if the hours are shortened the time before qualification is likely to be much longer?

Mr. Mellor : I am grateful to my hon. Friend for introducing into the debate certain points that have sometimes been missed. First, although junior doctors' hours are undoubtedly onerous throughout the service, it is a minority who work the hours that we all agree to be excessive. The last study carried out on the average number of hours worked in different specialties revealed that the average hours of work for a junior doctor in psychiatry were 46 hours per week, but in general surgery the figure rose to 67 hours per week, which is obviously very high. As my hon. Friend says, a key part of junior hospital doctors' training takes place on the ward, where they see difficult cases being treated. Plainly, any action taken to reduce the number of hours that junior doctors work must take into account the need for them to gain experience and to be capable when they become consultants--we hope that most will become consultants by their late thirties--of dealing with a wide range of problems.

Mr. Fearn : Is the Minister aware that nowhere is it laid down that junior doctors must work so many hours continuously? I stress the word "continuously". We know about the average figures, but it is the word "continuous" in which I am interested. Continuous working must detract from performance. Is the Minister taking any steps to stop continuous working?

Mr. Mellor : As the hon. Gentleman knows, we are in the middle of our initiative with a working party, consisting mainly of doctors, in each health district. We must see how that works out. The preliminary indications are that that is causing a reduction in the most onerous shifts in each region. The hon. Gentleman has made an interesting point about the number of hours that a person works, or during which he is on duty continuously, and whether that should be regulated. That is one of the matters that we have in our minds at present.

Mr. Ward : Does my hon. and learned Friend agree that the word "average" is a little suspicious because it implies that many people are working a good deal more than the average as well as the fact that others are working a good deal less? Does he agree that many constituents are complaining that some of the doctors have established their case? I hope that he will proceed with all vigour to do something about this. I should like to draw attention to an article in The Evening Standard --

Mr. Speaker : Order. This is Question Time.

Mr. Mellor : The last time that a major sustained effort was made to reduce the extremely onerous shift patterns of some junior doctors was in 1982 and it resulted in a 30 per cent. reduction in extreme shifts. We hope to achieve a similar result or even an enhanced rate of progress with the present initiative. My hon. Friend should be aware that some of the difficulties are structural. The NHS must offer 24-hour cover in every hospital unit throughout the land.

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Some of the ways in which junior doctors' hours could be cut--by rationalising services in each district on to one site, for example--would lead to equal concern among hon. Members if that meant that smaller hospital units had to be closed.

Mr. Robin Cook : If the Minister is so dissatisfied with the excessive hours of junior hospital doctors, why do the Government propose to resist tomorrow the Bill introduced in another place to reduce those excessive hours to 72 per week, which many doctors still regard as excessive? How can it be right to limit the hours for which lorry drivers can drive and airline pilots can fly, but wrong to limit the hours during which junior doctors can carry out complex medical treatment? If the hon. and learned Gentleman expects the House to take seriously his commitment to reducing those excessive hours, will he assure the House that he will withdraw the circular that he issued only last November requiring junior doctors to cover for colleagues on sick leave and thus work even longer hours than at present?

Mr. Mellor : The hon. Gentleman is seriously in error if he thinks it a legitimate criticism of Ministers that we should be taking steps to prevent the expansion of a system whereby the NHS is obliged to pay £900 per week for the services of locum doctors from private agencies. The hon. Gentleman should look for a golden thread of principle to run through his representations. It does not seem to be there in this instance.

The hon. Gentleman is excessively simplistic for a man of his supposed sophistication if he thinks that a parallel can be drawn between a lorry driver who can pull off a motorway into a lay-by when his hours of duty have expired and the need for the NHS to offer 24-hour cover in every one of its hospital units. My right hon. and learned Friend the Secretary of State has made it clear that he believes that a work pattern of 72 hours is an acceptable long-term basis, but immediate statutory intervention is far too simplistic to deal with the complex problem.

NHS Review

3. Mr. Allen : To ask the Secretary of State for Health when he anticipates making a statement to the House on the National Health Service review.

6. Mr. Macdonald : To ask the Secretary of State for Health what representations he has received concerning the Government's review of the National Health Service.

12. Mr. Squire : To ask the Secretary of State for Health if he will include the abolition of the regional health authorities in his review of the National Health Service.

18. Mr. Blunkett : To ask the Secretary of State for Health if it is his intention to bring forward proposals to remove local authority representatives from district health authorities.

20. Mr. Yeo : To ask the Secretary of State for Health what representations he has received regarding the working of the internal market of the National Health Service.

Mr. Kenneth Clarke : I shall be publishing a White Paper on Tuesday 31 January. I shall make a statement on that day.

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Mr. Allen : Is the Secretary of State aware that Nottingham district health authority which covers my constituency of Nottingham, North, as well as his own constituency, meets on Thursday? Will that be the last ever meeting at which there is local authority representation on the health authority? Is the right hon. and learned Gentleman aware that the health authority is underfunded by £8 million, even on his own reckoning? Will he use the review to put that money back into the health authority or will the review be used to fiddle the figures and get rid of the RAWP formula?

Mr. Clarke : Nottingham health authority, like all the others, is a statutory body and legislation would be required to change its composition or its powers. The hon. Gentleman quoted the figure of £8 million. That is the target for the spending set under the RAWP formula, and one to which the region is much nearer than it has ever been before. The target is not any measure of underfunding--the hon. Gentleman is misusing the figure when he quotes it in that way. It is a target towards which the Government have moved the health authority rapidly.

There has been a huge growth in the resources going to Nottingham health authority over the past few years, not least because of the Government's consistent policy of sharing resources more fairly across the country and making sure that they are provided more equally than they used to be.

Mr. Macdonald : Does the Secretary of State appreciate that the National Health Service spends less of its budget on administration and bureaucracy than Marks and Spencer does? Is he committed to maintaining that level of efficiency? If so, will he give a categorical assurance that as a percentage of the National Health Service budget administrative and bureaucratic costs will not increase once the review proposals are implemented?

Mr. Clarke : I am not responsible for Marks and Spencer, so I cannot make the instant comparison that the hon. Gentleman seeks to make. We need a non-bureaucratic and effective management system. Many of the figures bandied around about administrative costs of the National Health Service are not always what they appear because they tend to include only the staff costs of the health authorities which are, of course, just a small proportion of all the administration that goes on in hospitals and units throughout the country.

Mr. Squire : Does my right hon. and learned Friend accept that many people are concerned about the continuing high cost of bureaucracy in the Health Service and that many, if not all, of the powers currently exercised by the regional health authorities could be devolved to the district authorities if not to the hospitals? If the Department of the Environment can negotiate successfully with 400 local authorities, presumably my right hon. and learned Friend's Department can manage with fewer than 200 district authorities.

Mr. Clarke : What we want is good quality decision-making and the right choice of priorities and that needs clear lines of management responsibility and accountability. We want good, effective management involving all the people in the Health Service and no bureaucratic systems at all. My hon. Friend will have to judge our proposals when he sees them in the White Paper. I agree with his instincts that the best decision- making is

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often taken at the lowest level in large organisations and in this case it should take place as near as possible to the place where the patient has to be treated.

Mr. Blunkett : Just in case I am accused by The Guardian of reading my question, as I was last Friday, I shall put my notes down on the Bench.

Will the Secretary of State confirm that, if the press speculation is correct, he believes that elected members at local level interfere politically with the management process? If he believes that, does he agree that that applies at national level and that if he removes elected members who are accountable at local level the first elected member who should be removed from interference with the Health Service is himself?

Mr. Clarke : I sympathise with what the hon. Gentleman says about reporting in The Guardian. It is because we have such experiences that I do not always answer questions which begin, "If speculations in the press are to be believed". I ask the hon. Gentleman to wait until he has read the White Paper proposals and the arguments in favour of them. I should then be grateful for his contribution and comments on the arguments.

Mr. Yeo : Does my right hon. and learned Friend agree that the introduction of a more free internal market within the NHS would contribute, first, to a reduction in waiting lists in some areas and secondly, to keeping the costs of treatment down ; and, thirdly, would enable those doctors and nurses who are particularly good at providing certain kinds of treatment to offer their skills for the benefit of a larger number of patients?

Mr. Clarke : There is now widespread interest in the concept of internal markets inside the NHS. The Government's review team has probably taken the work on internal markets and the possibility of turning that idea into a practical reality further than most other groups.

The point of interest in this subject is exactly as my hon. Friend says. We are seeking methods whereby money can move to those places where it will be used most effectively on behalf of the patients, so that where good quality care is being given by hospitals in response to the demands of GPs and their patients the resources will follow quickly and directly and people will have the incentive to do more.

Mr. Gill : What assurance can my right hon. and learned Friend give the House that under the terms of the review urgent attention will be paid to the important aspect of putting managers in a position to manage without the unnecessary constraints of bureaucracy?

Mr. Clarke : That must be an important aim in strengthening the NHS. We want everyone in the Health Service--managers, doctors, nurses and others--to be in a position to take clear, quick decisions in the interests of the patient. At the moment, as we all know, that clear, quick decision- making and choice of priority is not always made and the system is certainly capable of some improvement.

Mr. Rowlands : If the review is meant to cover the question of contracts for consultants, will it also cover the abuse that appears to be taking place whereby those consultants are recruiting their private patients from long waiting lists, particularly in the hip section and the ear, nose and throat section?

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Mr. Clarke : Waiting lists are shorter than they used to be and we are making progress in bringing down waiting times. The waiting times initiative has already enabled 200,000 extra in-patients and 120,000 extra day cases to be treated. The key is waiting times. I can assure the hon. Gentleman that the Government are determined to put a great deal of effort into getting waiting times down to more acceptable levels in areas and specialties where they are excessive, although in a great deal of the service and in many specialties there are no longer excessive waiting times and I am glad to say that we are making substantial progress.

Mr. Atkinson : Will my right hon. and learned Friend's White Paper next week also include his response to the Griffiths report on community care and if not, when we can expect that response?

Mr. Clarke : No, it will not, but we owe the House and Sir Roy Griffiths and his colleagues a response to their report. It is an important subject and I hope to come forward with the Government's conclusions in the not too distant future.

Mr. Robin Cook : Has not the Secretary of State's White Paper now been so thoroughly leaked that it is already shot full of holes? Now that he has been good enough to give us a date for bringing forward his White Paper, will he tell us when he intends to respond to the Griffiths report which has been gathering dust for almost a year? Does his White Paper say anything about community care for the elderly? Does he recognise that if the only thing that his White Paper offers the elderly is a tax subsidy for private medical care it will be transparent that the only health problems he is worried about are those out of which someone else can make a profit?

Mr. Clarke : It is certainly true that there has been a great deal of speculation about the White Paper and it was predictable that the hon. Gentleman should denounce each and every proposal that he thinks we shall make. At least the knee-jerk reactions of the Labour party are now out of the way. I hope that we have cleared the ground for a serious discussion when the White Paper appears on 31 January. We shall follow it up with our reactions to and our decisions on the Griffiths proposals on community care as soon as possible.

Infant Mortality

4. Mr. Couchman : To ask the Secretary of State for Health what the latest available figure is for the infant mortality rate ; and if he will make a statement.

The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman) : The latest available annual figure for the infant mortality rate in England and Wales is for 1987, and is 9.2 deaths per 1,000 live births. That is the lowest figure since records started.

Mr. Couchman : I am grateful to my hon. Friend for that encouraging reply, but he will have received reports about the spate of cot deaths reported late last week. Such deaths are always traumatic for the parents. What steps is the Department taking to investigate the strange coincidence of six deaths within a matter of a few hours in a fairly narrow geographical area?

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Mr. Freeman : I agree with my hon. Friend that they are traumatic. There is no easy answer, but over the past eight years infant mortality, which includes cot deaths, has shown a significant improvement, from about 12.8 per 1,000 to 9.2 per 1,000. I assure my hon. Friend that I will pursue an explanation for the unexplained coincidence of a number of cot deaths with the health authorities in Surrey and Hampshire.

Mr. Frank Field : Given our poor standing in the international league table for infant mortality, why are the Government content to let so many babies die unnecessarily?

Mr. Freeman : I do not accept the charge or allegation made by the hon. Gentleman. In comparing the record of this country with that of other countries one must bear in mind that we have a higher proportion of lower birth weight babies. That in turn may be due to the fact, as my hon. and learned Friend the Minister of State recently pointed out, that we have a higher incidence of teenage mothers who smoke.

Mrs. Maureen Hicks : I welcome the reduction in the perinatal mortality rates nationally, and certainly in the west midlands, but does my hon. Friend agree that that heightens the responsibility that we must show for pregnant mothers in my constituency, where I regret to say that the figure has increased to an all-time high? May I have an assurance that the Government recognise our problems and will investigate them without further ado?

Mr. Freeman : I can give my hon. Friend that assurance. The Government certainly take this seriously. Since 1980 there has been a threefold increase in the number of intensive care cots available for such cases.

Rev. Martin Smyth : Although I welcome the movement to reduce the figures, can the Minister assure us that the policy of not operating on children with heart problems who have Down's syndrome is not endorsed by the Government? They can have such treatment in other countries.

Mr. Freeman : The hon. Gentleman asked a detailed question, about which I shall write to him.


5. Mr. Marlow : To ask the Secretary of State for Health to what extent AIDS treatment is made available to foreigners.

Mr. Mellor : Whether free National Health Service hospital treatment for AIDS, or any other condition, is made available is not determined primarily by a patient's nationality but by whether the person is ordinarily resident in the United Kingdom.

Mr. Marlow : My hon. Friend will have heard reports last year that almost half the HIV-positive patients in one London hospital came from Dublin. He will also know of allegations that in the Irish Republic AIDS patients are publicly named and forcibly segregated unless they leave. Will my hon. Friend undertake to the House that the British taxpayer is not spending taxpayers' money on an AIDS drain from the Irish Republic and other foreign countries?

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Mr. Mellor : I know of no evidence for any such AIDS drain. Of course, I shall consider any evidence--as against assertion--that my hon. Friend might have.

Mrs. Margaret Ewing : Given that the problem of AIDS is international and that its resolution can be found only through international co-operation, does the Minister share my concern that the major work undertaken by Dr. Jarrett at Glasgow university may well be threatened by the proposed closure of the veterinary school there? Will his Department therefore join the many people in all parts of the House and from all walks of life who are trying to dissuade the University Grants Committee from following that ridiculous course?

Mr. Mellor : That was a rather contrived way of introducing a question which is for another Department to consider. If the hon. Lady feels that it is a matter for congratulation--as obviously she does--I add to the congratulations by commending her for her ingenuity, but I cannot add anything in my answer.

Mr. Alexander : While it may be regrettable that some foreigners are taking advantage of the facilities in Britain, is it not the case that AIDS is a scourge and should be dealt with wherever it is found, especially if it is found in this country?

Mr. Mellor ; I am sure that that is precisely right. In fact, in accordance with international agreements, anybody who wishes to have an AIDS test while in the United Kingdom can have one. Indeed, AIDS knows no national boundaries, nor can it ever be confined within one national area or continent. We must all work together to deal with that scourge. I hope that the House has been encouraged by the compliments paid to us by Dr. Jonathan Mann of the World Health Organisation for our efforts in giving a lead in this matter.

Staff Regrading

7. Mr. Ieuan Wyn Jones : To ask the Secretary of State for Health if he will make a statement on the operation of the appeals procedure set up following the regrading of hospital staff.

Mr. Kenneth Clarke : These appeals are being dealt with under a long -standing general Whitley council agreement to which the nursing trades unions are a party and which they insisted should apply to the recent regrading exercise. I have asked health authority chairmen to adopt a range of measures aimed at ensuring that the appeals process works quickly and effectively.

Mr. Jones : Will the Minister tell the House to what extent his Department will make available overtime payments or extra staff, because of the increased workload of managers, regrading officers and union stewards involved in these appeal procedures? If that is his Department's intention, will he make available extra resources to cover that extra work?

Mr. Clarke : All the staff who, in some places, have to put in a considerable amount of work to handle these appeals are being paid accordingly, and in line with national agreements which we have with them. I accept that in some places the appeals process is putting a considerable extra burden on management and in some places, no doubt, on the union side, too. We understand

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that shop stewards are finding it difficult to keep up with the number of appeals. It is a pity that in many places nurses and midwives have been encouraged to put in appeals, regardless of the merits. I believe that everyone is slightly paying the price for the fact that the system was, I dare say, deliberately overloaded in some places. I know that everyone is trying to ensure that the process is carried out and that cases of individual mistake are corrected as soon as possible.

Mr. Neil Hamilton : Is it not the case that the vast majority of nurses and midwives are satisfied with the results of the regrading exercise and that a large number of the appeals against the decisions are politically motivated by the National Union of Public Employees and Confederation of Health Service Employees, which is using its own members-- gulling and duping them and using them as their political war-horses rather than acting in their best interests by accepting what they have been given?

Mr. Clarke : I believe that my hon. Friend's assertion is self- evidently true throughout the country. He accurately describes the position of the majority of nurses and midwives. COHSE, NUPE and the Labour party have tried to stir up discontent and have tried to make political capital out of the situation. Unfortunately, by overloading the appeals procedure in some cases, they have been getting in the way of those people who have a genuine query about their grading and wish to have it sorted out by a sensible appeals process.

Mr. Canavan : Will the Minister make it clear to all health boards that enough additional resources will be made available to meet the results of successful appeals, and that the number of successful appeals will not be predetermined by the amount of money in the kitty?

Mr. Clarke : The appeals are being determined in line with the guidelines which were set out when we started. They are not in any way determined by any artificial cash limit. I am satisfied that we have funded this generous nurses' and midwives' pay settlement in full. Indeed, we funded it in full using the health authority's own figures. I do not foresee any cash problems arising as a result.

Dame Elaine Kellett-Bowman : I thank my right hon. and learned Friend for remedying the anomaly whereby fully qualified nurses when entering midwifery training were actually losing money, thus obviating the number of appeals. Will he now ensure that any charge nurse undertaking additional responsibilities--for example, moving from grade I to grade 2-- will receive some salary increase at the same time?

Mr. Clarke : We certainly were flexible on some of the points which arose in our discussions on the grading structure. One of the changes that we made was to deal with the problem of midwifery students, and I am glad that my hon. Friend is satisfied with the result. Nurses will steadily pursue their careers by moving to posts that carry heavier responsibilities. For the first time we have a career structure and a grading system for nurses which assure that, as a nurse acquires more skill and responsibility, money is targeted upon the post that he or she then occupies. I believe that most nurses look forward to the opportunities with which they are now presented.

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Mr. Allen McKay : Does the Minister realise that it was disastrous to undertake the regrading exercise at the present time? Is he aware that a lot of nurses are dissatisfied and will be leaving the Health Service? Can he guarantee that payment will be retrospective? As the reviews will take years rather than months, will interest payments be paid on top of the pay awarded?

Mr. Clarke : I am sorry that the hon. Gentleman thinks that it was wrong to regrade the nursing profession and to provide the career structure that I have just described. The hon. Gentleman is criticising not only myself, the Government and the management of the NHS, but all the trade unions which were party to the regrading exercise and which, at first, welcomed the career structure that it created.

We are trying to deal with the appeals as rapidly as possible and if it turns out that any nurse was incorrectly graded when the exercise was first carried out, that post will be graded properly and any back pay due from last April will be paid to the nurse in question.

Royal National Orthopaedic Hospital

8. Mr. Dykes : To ask the Secretary of State for Health if he has received any further representations from relevant interested groups and individuals on the proposed closure of the royal national orthopaedic hospital's accident and emergency unit at Stanmore, Middlesex, following the Minister of State's letter to the hon. Member for Harrow, East on 22 December 1988.

Mr. Mellor : As at 18 January 1988 we had received five further representations.

Mr. Dykes : After the sad and regrettable decision to close the unit, especially as it is so close to the M1, I hope that, in future, the Minister of State will not underestimate the vital importance of keeping the rest of the hospital on its present site, if at all possible.

Mr. Mellor : Obviously, I am sorry that my hon. Friend has reservations about the closure of the accident and emergency unit. He will be aware of the pressure that we are under as a result of the report from the Royal College of Surgeons and others, to ensure that accident and emergency units throughout the country are capable of dealing with the full range of emergencies that might come to them. That means centralising on a fewer number of sites but, in fulfilling that need, I regret it if it has had the effect of damaging my hon. Friend's constituents' confidence in the service.

I am happy to tell my hon. Friend that we are absolutely committed to the continuation of the royal national orthopaedic hospital, but whether it remains on its present site is still to be determined.

Operating Theatres

9. Mr. Colin Shepherd : To ask the Secretary of State for Health what steps he is taking to establish the costs of operating theatre procedures.

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