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House of Commons

Tuesday 6 July 1993

The House met at half-past Two o'clock


[Madam Speaker-- in the Chair ]


Harris Tweed Bill


Bill read the Third time, and passed, with amendments.

Oral Answers to Questions


London Implementation Group

1. Dr. Goodson-Wickes : To ask the Secretary of State for Health what is the proposed programme for the Government's response to the report of the London implementation group.

5. Mr. Tony Banks : To ask the Secretary of State for Health when she expects to conclude the reorganisation of hospital provision in London.

The Secretary of State for Health (Mrs. Virginia Bottomley) : "Making London Better" sets out the timetable for improving London's health service, including our £170 million programme for strengthening primary care in the capital. The need for change is most urgent in inner London, where a number of hospital site option appraisals are already under way. Another key element will be the recommendations of the recently published independent specialty review reports. The main proposals for the future configuration of services in inner London will come forward in the autumn. Any major proposals to change services will, of course, be subject to full public consultation.

Dr. Goodson-Wickes : I recognise my right hon. Friend's problems and motives in rationalising health care in London. In the present economic climate, and with particular reference to Bart's, about which there has been so much public concern, can she give the House an absolute assurance that adequate funds will be available for the movement of units from Bart's to the Royal London hospital? If she is unable to give the House that assurance, will she say that the units, which have been recognised as centres of excellence in the specialty reviews and generally, will be allowed to operate on two sites so that nothing of value is destroyed?

Mrs. Bottomley : I give my hon. Friend a clear assurance that the intention of "Making London Better" is to improve and strengthen the specialist services. Independent commentator after independent commentator has reinforced the point that the London specialty services are fragmented, duplicate each other and will not

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be national, let alone international, centres of excellence unless change is embraced. My hon. Friend is right ; we need to take great care and show consideration for preserving excellence, but I commend to him the words of Professor Besser when he said :

"Bart's would not have survived 870 years if it had not been flexible."

I welcome the discussions that are under way between Bart's and the Royal London hospital and I am sure that strengthened services and the safeguarding of excellence will emerge out of them.

Mr. Banks : What does the right hon. Lady have to say to the statement made by Mr. Sandy Macara, the new chairman of the British Medical Association, who said that the national health service would be dead inside seven years unless the rot was stopped now and that it was underfunded by £6 billion?

What does the right hon. Lady have to say to Professor Jarman, who published an article a couple of weeks ago in the British Medical Journal that proved conclusively that London was not overstocked with hospital beds? When she answers, will she please not read out a list of misleading statistics produced by Conservative central office--as she normally does-- because the more she does that, the more she sounds like a Dalek in a nurse's uniform?

Mrs. Bottomley : The hon. Gentleman and other hon. Members should read the edition of the British Medical Journal from the week after the specialty reviews were reported, which said :

"The specialty reviews show clearly that some clinical services in London are not as good as they should be Those who ultimately make the decisions on London should not lose sight this summer of the fact that their aim is to improve services for Londoners and the people of the Thames regions it is not to protect institutions."

It is well understand that primary care is not up to a sufficient standard in London. I commend to the hon. Gentleman some of the developments in his area, such as the increase in the number of community psychiatric nurses and district nurses and the investment in primary care, as well as the £11 million development at Homerton hospital.

Mr. Congdon : Will my right hon. Friend bear in mind the need to implement the changes to health care in London at a sensible rate, in line with the changes in demand? Will she ensure that the changes in the number of acute beds are in line both with changes in demand and with improvements in primary health care?

Mrs. Bottomley : I give my hon. Friend that clear assurance. We said that we would not make progress in London until we had invested in primary care. This year, £43.5 million is going into primary care, in 78 different capital schemes. Tomorrow, I shall open the South Westminster health centre, a £1.7 million investment in family doctor and community services. There is an urgent need to take our proposals forward because, all over the south-east, district health authorities are changing their patterns of referral. The London specialty services treat, on average, about half the number of cancer patients that are treated in other parts of the country, so it is extremely urgent, if their excellence and their reputations are to be protected, that we take change forward.

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Ms Primarolo : Does the Secretary of State agree that the way in which she has handled the Tomlinson report and the specialty reviews has blighted the whole of London's health service and that she is responsible for the low morale of staff, for undermining patients' confidence, for talking down the national health service and for causing chaos, because she does not have a clue what to do now that the reforms have failed? Are not the reforms that she said would save the national health service destroying it like a creeping cancer?

Mrs. Bottomley : Again, I urge the hon. Lady to do her homework. I commend the words of Christopher Ward, a consultant at Charing Cross hospital, who said :

"Too many specialist services are supplied to the dwindling population of London. These vary from the excellent to the inadequate".

I commend also the words of Paddy Ross, of the Joint Consultants Committee, who said :

"Ministers should be congratulated on the way they have responded to the Tomlinson Report. As a result of meaningful consultations they have produced a Government response the broad thrust of which is supported by the medical profession at national level".

There is great agreement that changes need to come. We shall move as swiftly as we reasonably can. With such serious decisions to be made, it is right to take properly into account the independent specialty reviews and the reviews of the special health authority research which will be published shortly.

Mr. Couchman : As my right hon. Friend takes the momentous decisions that she has to take to strengthen primary health care in London, will she bear in mind the fact that the destruction of a world-famous centre such as the Royal Marsden hospital would need justification stronger than that thus far offered by the differing opinions of Tomlinson and of the review group? Furthermore, will she also take into account the facts that London's gain over many years has been the loss of areas such as mine and that she will have to bear a great burden in deciding where to direct the resources that she takes from London and redistributes to the provinces?

Mrs. Bottomley : I certainly respond to the second part of my hon. Friend's remarks, because London has been spending 20 per cent. of the money on 15 per cent. of the people. There have been improvements, but there has been a distortion in the balance of provision in London because of the numerous duplicated speciality services and the great number of sites and institutions that have not changed at the same pace as the delivery of health care and the great investment outside London.

In reply to what my hon. Friend said about the Royal Marsden, I want to do nothing more than to protect and enhance London's national and international reputation for clinical services, research and education. My hon. Friend and other hon. Members would be hard pressed to find any authentic representatives of the academic or the medical profession who do not agree that services in London are duplicated and too small and that they need reintegration and rationalisation to become stronger.

Health Authority Mergers

2. Mr. Pike : To ask the Secretary of State for Health what recent representations she has received on the subject of health authority mergers.

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The Parliamentary Under-Secretary of State for Health (Mr. Tom Sackville) : I have received a number of representations on that subject, including one from the hon. Member for Burnley (Mr. Pike). Most recently, I had a meeting with my hon. Friend the Member for Macclesfield (Mr. Winterton).

Mr. Pike : As we move towards the merger of the two health authorities in north-east Lancashire, can the Minister give the assurance that when the consultation takes place it will be genuine, and not a total sham, as was the consultation before we moved to trust status? Will he also guarantee that, as a result of the merger, there will not be a rationalisation that will provide less effective local services to the people of north-east Lancashire?

Mr. Sackville : The answer to the hon. Gentleman's first point is that I can give him that assurance. Those to be consulted will include local Members of Parliament, any districts or family health services authorities that are affected, local community health councils, interested local authorities, trusts, universities and professional and representative organisations.

On the second point, there is every reason to suppose that the new purchasing arrangements will be of great benefit to patients in the hon. Gentleman's area.

Mr. Nicholas Winterton : My hon. Friend is well aware that Macclesfield borough council, Crewe and Nantwich borough council, Macclesfield community health council, myself, my hon. Friend the Member for Congleton (Mrs. Winterton) and the hon. Member for Crewe and Nantwich (Mrs. Dunwoody) are strongly opposed to the proposed merger of Crewe and Macclesfield health authorities.

Does my hon. Friend agree that those bodies and individuals are more representative of the people of that area than anyone else? Will he take their representations seriously into account? Does he accept that it would be better for the Government to halt the merger of districts until they have considered the merger of regions, and perhaps put the Mersey and North Western regions together, enabling Macclesfield to have a more natural partner to the north rather than Crewe to the south?

Mr. Sackville : I am well aware of my hon. Friend's views. He has failed to mention all the bodies and organisations that are in favour of the merger. I must remind my hon. Friend, however, that if he wants the best for the patients in his constituency, he will want a stronger purchaser with a larger number of residents, so that the purchaser has more influence with providers. That is the whole point of the purchaser-provider split.

Mrs. Dunwoody : Is the Minister aware that that was the greatest load of claptrap that even he has ever uttered? There is no reasonable argument--medical, political or economic--for jamming together those two health authorities, which do not have common services and do not want the amalgamation. Will the Minister admit that he has no more intention of taking any notice of local people or local Members of Parliament than he has of learning to fly around the Chamber without a kite?

Mr. Sackville : The hon. Lady must realise that common services are not the main point. The main point is that a strong purchaser representing her constituents will be better able to assess the health needs of the whole area.

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Mental Health Act 1983

3. Mr. Clifton-Brown : To ask the Secretary of State for Health if she will make a statement on the working of section 2 of the Mental Health Act 1983.

The Parliamentary Under-Secretary of State for Health (Mr. John Bowis) : Section 2 of the Mental Health Act 1983 provides for a patient suffering from mental disorder to be compulsorily admitted to hospital for assessment for a maximum of 28 days. We have been reviewing the general adequacy of the Act's provisions in relation to vulnerable or potentially dangerous psychiatric patients and my right hon. Friend the Secretary of State will announce her conclusions on this shortly.

Mr. Clifton-Brown : I have given previous notice of three cases to my hon. Friend. The first involved a patient who was detained on inconclusive evidence, with subsequent devasting damage to the patient's family. The second case involved a patient whom two doctors had certified should be detained. The social worker refused to detain the patient, who then went outside and bopped the social worker on the head. The patient had to be brought inside and detained. In the third case, the patient could not get any evidence--

Madam Speaker : The hon. Gentleman is trying the patience of the House. Will he come to his question to the Minister?

Mr. Clifton-Brown : I am grateful for your advice, Madam Speaker. In view of the abuses of the current system, will my hon. Friend consider reviewing the system whereby a mental health tribunal takes 21 days to settle such cases? Will my hon. Friend set up a quicker conciliation procedure?

Mr. Bowis : I am grateful to my hon. Friend for giving me notes of the cases to which he referred. As he said, some of the cases were referred too quickly and others were not referred quickly enough. I am seeking comments from the authorities involved about the cases raised. Section 2 requires a tribunal to act within seven days, not 21. Under the 1983 Act, the Mental Health Act Commission acts on behalf of my right hon. Friend the Secretary of State in keeping the working of the Act under review. That can include any aspect of the Act.

Ms Lynne : Can the Minister explain how it can be right that people detained under section 2 of the Mental Health Act 1983 have no statutory right to after-care under section 117? Will he ask the Secretary of State for Health to use her powers to direct health authorities, local authorities and NHS trusts to have some minimum standard of after-care, thus preventing mental health patients or ex-patients who recognise that they need treatment going for help and being turned away?

Mr. Bowis : It is our wish that everyone who needs treatment and after-care should receive it. That is why we have put in place the care programme approach, which ensures that everyone who leaves institutional care has a programme of treatment and social welfare and a key worker to assist. The mental health task force under David King is travelling around the country ensuring that social services departments are better able to receive such people and, indeed, to look after them while they are in the community.

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Mrs. Browning : Is my hon. Friend aware that, for example, in rural communities, schizophrenic patients who from time to time have to be sectioned find that when housing is found for them they are housed in a large urban conurbation? That exacerbates their problem because they are away from the area where they are known by the local community and the area with which they are familiar. Will my hon. Friend examine that issue? It is a particular problem in rural constituencies such as mine.

Mr. Bowis : I accept entirely that the point that my hon. Friend raises is important. The programme for housing between the health authority and the relevant local authority social services department should be put in place before the patient is returned to the community. Certainly, the wishes and needs of the patient as well as of the patient's carers will be taken into account. I am sure that needs will be met in the way that my hon. Friend wishes.

Mr. Hinchliffe : Is the Minister aware of the widespread concern that the Government's only apparent response to the increasing lack of public confidence in community care is to amend the mental health legislation and strengthen its provisions? Is not it astonishing that the Government admitted in the last oral Health questions, that they did not have the least idea where thousands of psychiatric patients who had been discharged while the Government have been in power had gone?

When will the Government start on the basics of community care : guaranteed after-care and support, proper accommodation, and care plans that are agreed when patients leave hospital and regularly reviewed when they are in the community? When will the Government realise that community care must be much more than simply closing hospitals and saving public expenditure?

Mr. Bowis : I wonder whether it is not time that the hon. Gentleman understood that it is our policy that everyone who has a mental health problem should be considered carefully and have his or her interests taken into account. It is not the case that beds are closed and people are thrown out into the community ; bed closures must be set against a much wider range of provision in the community for former long-stay patients.

If the hon. Gentleman wishes to exchange facts, why does not he explain the real fact about funding mental health provision in Britain at the rate of £2 billion every year ; the real fact about trebling the number of community psychiatric nurses ; the real fact about trebling independent sector residential places ; the real fact that funding for local authority services for the mentally ill has been increased by 86 per cent. in real terms ; and the fact that mental health specific grant has increased this year by £13 million to £34.4 million, including £250,000 to the hon. Gentleman's borough?

Cardiac Unit, Plymouth

4. Mr. Streeter : To ask the Secretary of State for Health what progress has been made regarding plans for a specialist cardiac unit at Plymouth.

Mr. Sackville : I understand that South Western regional health authority has asked local health districts to prepare a business case for the development of a cardiac surgery unit at Derriford hospital in Plymouth.

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Mr. Streeter : I thank my hon. Friend for that reply. Does he agree that it is simply not acceptable for people living in Plymouth, which is the 14th largest city in the country, to have to travel 120 miles to Bristol or 240 miles to London for cardiac treatment? Does that not further show the urgent need to reallocate the surplus capacity in London's specialty services to ensure that those vital facilities are available for the regions where they are badly needed and would be warmly welcomed?

Mr. Sackville : I have visited my hon. Friend's constituency and talked to some of the patients at Derriford hospital who have had to travel large distances and I am aware of the problem. However, my hon. Friend should be aware that a decision on a cardiac unit is not taken lightly : the unit must be of a certain size. He will be aware also that, of those patients currently treated at Bristol, some will continue to be referred to Bristol and others may well continue to be referred to Oxford or London. Before any such decision can be taken, it has to be proved that there will be a sufficient number of referrals to a new cardiac unit.

Mr. Jamieson : Is the Minister aware that the incidence of heart disease in the Plymouth health authority area is among the highest in the country, yet that is one of the few areas of England without a dedicated unit to carry out angioplasty and bypass operations? As hundreds of people are travelling from Devon and Cornwall each year for cardiac treatment in London and Bristol, will the hon. Gentleman now give urgent consideration to providing funds so that such a unit can be set up in Plymouth without further delay?

Mr. Sackville : The hon. Gentleman should not pretend that it has been a matter of resources. It has been a matter of the need to refer to a suitable centre. He will know, perhaps, that the region is intending to cater for 316 coronary artery bypass grafts per million population. That is above the national average of 300. That increase may justify a new centre.

Mr. Harris : Does my hon. Friend appreciate the fact that a cardiac unit in Plymouth would serve not only Plymouth and that part of Devon but Cornwall? It is a long day's march from Cornwall to London, as I and other hon. Members from Cornwall know. It is also a long distance from my constituency to Bristol. Will my hon. Friend examine that matter with urgency and sympathy?

Mr. Sackville : The long distances are a major factor. It would appear that, if there is to be a second centre, the most suitable location would be Plymouth.

Trent Regional Health Authority

6. Mr. Kevin Hughes : To ask the Secretary of State for Health if she will make a statement about the management of Trent regional health authority.

Mrs. Virginia Bottomley : Trent regional health authority has an excellent record in the delivery of health services. In the past four years, for example, it has seen a 75 per cent. increase in the use of day surgery, releasing resources to treat more patients. Long waiting times, in particular, have fallen dramatically. Almost a third of the region's population now benefit from having a GP fund

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holder, which is well ahead of the national average. We expect that, from next year, all but four of the region's units will have been strengthened by NHS trust status.

Mr. Hughes : The Secretary of State is one of the few people left with confidence in Trent regional health authority. Is she aware of the catalogue of disasters going uninvestigated in that authority : Beverley Allitt ; brain damaged babies at Doncaster royal infirmary ; Neil Silvester, the psychiatrist who released one of his patients, who, two days later, stabbed to death an innocent 12-year-old girl in Doncaster ; and, recently, an unfortunate stabbing in Doncaster royal infirmary?

Public inquiries have been called for in all those cases. All were refused. When will we have a public inquiry into that catalogue of disasters? If the Secretary of State refuses, may we have a public inquiry into the management of Trent regional health authority?

Mrs. Bottomley : The hon. Gentleman cites a number of cases, all of which are complex and, as he rightly says, deeply concerning. I commend an article from the Solicitors' Journal that identifies the cases in which a public inquiry is the best approach as distinct from an investigative inquiry where the results are revealed. It states that the format of the public inquiry is quite unsuited to the delicate and sensitive issues of health and child care matters, and that

"The only criteria to be satisfied in the Allitt case are that : the inquiry team are competent and independent

that they have access to the information

that witnesses are confident to come forward and give their evidence

that the report is published in full".

It goes on to say that clearly the decision of a private inquiry "will satisfy the overriding concern of the parents, the medical profession and the public that the truth be known".

That is important advice.

All the cases that the hon. Gentleman cited from his constituency have been investigated. The health advisory service is currently considering the care of the mentally ill in the hon. Gentleman's constituency. At the same time, in his constituency as elsewhere, there have been great improvements in care. No one in Doncaster generally has to wait more than 18 months, 12 months for a cataract operation or nine months for hip and knee operations.

Mr. Blunkett : Will the Secretary of State tell the House why she is refusing to meet the parents of Beverley Allitt's victims unless they agree not to discuss the proceedings of the Clothier committee, and why she is refusing a public inquiry on a day when the Clinical Standards Advisory Group has declared the devastating and indicting state of neonatal intensive care facilities in Britain? Does the right hon. Lady agree with the advisory group that the market in health has failed, that there is a need for proper health planning and that, unless that takes place, people throughout Britain can have no faith in the national health service under the right hon. Lady's tutelage?

Mrs. Bottomley : That is another typical example of the way in which the hon. Gentleman fails to understand the changes that have been taking place in the health service. The Clinical Standards Advisory Group was set up by the Government precisely to advise on specialist services. It certainly does not say that they are in any way jeopardised

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by the changes that have taken place. Its advice must be considered by purchasers in securing ever-increasing standards of care for their local health authorities.

I have made it clear that I am happy to meet the parents of Beverley Allitt's victims and I have met a number of them informally. At the moment, judicial matters are under way. In particular, I refer the hon. Gentleman to the comments of the South Lincolnshire community health council. My wishes are those of the parents and staff--to get to the bottom of the case, to reveal all the facts, to publish the report and to ensure that the lessons are learnt. There has already been a lengthy criminal trial and an independent management investigation. The community health council stated : "The nature of a public inquiry with its adversarial atmosphere and the length of time that such proceedings demand may not necessarily establish the truth nor at the end of the day throw a lot of light on what actually happened."

It is the opinion of Sir Cecil Clothier, a distinguished, eminent and independent Queen's counsel, that that is not the way to get to the truth.

The Health of the Nation"

7. Mr. Callaghan : To ask the Secretary of State for Health if she will make a statement on the implementation of "The Health of the Nation".

Mrs. Virginia Bottomley : The White Paper, "The Health of the Nation", which was published a year ago, has been widely welcomed both within the NHS and further afield, not least by the World Health Organisation which described it as a model for others to follow. Progress towards meeting the targets set out in the White Paper is generally good. A wide range of activities is under way to ensure that we secure the improvements in health which are the overall aim of our policy. Much of the work is being reflected this week in a range of publications and events to mark the first anniversary of the White Paper.

Mr. Callaghan : I thank the Secretary of State for that rosy report on the state of the nation's health, but can she justify to the House her proposals to close so many of the nation's hospitals, including five in north Manchester alone? Is she aware that there is such a wave of anger that this weekend 500 people took to the streets of north Manchester opposing the closure of the Booth Hall children's hospital? In the light of that, will she reconsider her decision to close that hospital?

Mrs. Bottomley : As the hon. Gentleman knows, no decision has been taken on that matter, but the health of the nation cannot be measured in institutions which were built for generations past. Investment in health is important in primary care, family doctors and community nurses, emphasising prevention as well as cure. In the hon. Gentleman's health authority since 1979 there has been an increase of half as much again in the number of day cases, a two thirds fall in the one-year waiters, a 59 per cent.--nearly a 60 per cent.--increase in the number of general practitioners and a 67 per cent. increase in the number of dentists. That is a clear investment in health. Health is not only about institutions--in this country or anywhere else in the world.

Mrs. Roe : Does my right hon. Friend agree that "The Health of the Nation" White Paper has taken the health service a giant step forward towards its original goal of

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securing improvements in the overall state of health? Does she also agree that the Labour party is constantly displaying its lack of vision by continuing to focus on input measures, such as the number of beds, when the health service is changing and the emphasis should be on improving health?

Mrs. Bottomley : My hon. Friend is exactly right. The health service should not be measured by the number of beds. It is not a S, which we have at last been able to set in place so long after its establishment, is that it is a health service, not an illness service. It is about health, not health institutions. It is about prevention as well as cure. "The Health of the Nation" strategy, following the improvements in the family doctor services, "Working for Patients" and the establishment of trusts, is the third leg of the stool that will lead to a health service that will continue to be the envy of the world into the next century.

Mr. Blunkett : Given the Secretary of State's special understanding of the feelings and emotions of unmarried mothers, will she denounce as insensitive and hypocritical the comments made at the weekend by the Parliamentary Under-Secretary of State for Health, the hon. Member for Bolton, West (Mr. Sackville), who speaks for a Government who have cut family planning resources, who have reduced the school health service, who have failed to tackle teenage pregnancies and whose policies are designed to undermine and destroy rather than build up and secure responsibility and commitment to the family?

Mrs. Bottomley : I am a little surprised by the hon. Gentleman's approach. Be that as it may, however, I believe strongly that children need families. My hon. Friend the Parliamentary Under-Secretary of State was pointing out that rabid ideas of feminism are not the best approach to bringing up children and that children need mothers as well as fathers. I believe that my hon. Friend is exactly right and I also congratulate him on his work in talking about the importance of sex education in schools, where he has been taking a clear line that children need to be prepared for the world in which they are to live.

Family planning services have changed dramatically over the years. Now, 98 per cent. of GPs provide family planning services. That is why we have had a review to ensure that the clinics are focused on the needs of today and tomorrow and especially on the needs of the young.

Mr. Sims : One of the key aims of "The Health of the Nation" is a reduction in the incidence of coronary heart disease, in which two contributory factors are smoking and diet. I congratulate my right hon. Friend and the Government on their success before the European Court on the question of health warnings on cigarette packets, but can she tell us what steps she proposes to take to reduce smoking among 11 to 15-year-olds in the light of the chief medical officer's concern that targets may not be reached? Can she also tell us what success the nutritional task force, which she appointed in December, has had in persuading us all to follow healthier diets?

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Mrs. Bottomley : My hon. Friend the Member for Chislehurst (Mr. Sims) has long been a champion in the fight against smoking. He will know that we have had greater success than almost any other European country in reducing smoking. Only the Netherlands has a better record than ours. The Netherlands shares our approach to the voluntary agreement on tobacco advertising, but also our policy of taking vigorous and determined action to ensure that we get the message home to young people as well as their parents. Children of parents who strongly disapprove of smoking are seven times less likely to smoke than other children.

Our success at the European Court is an example of our firm intent. The health warnings on our cigarette packets are 50 per cent. bigger than in any other country and we have chosen to use the most direct messages on those packages. We shall continue to strengthen the campaign because we intend to meet the target by the end of the century. In particular, as my hon. Friend rightly suggests, we need to renew the campaign against young people smoking.

The nutrition task force produced its new programme this morning. I hope that all hon. Members will study the programme carefully and let us have any further advice that can change the dietary habits of us all.

Royal Free Hospital

8. Ms Glenda Jackson : To ask the Secretary of State for Health if she will make a statement on the future of the Royal Free hospital in the pattern of London's health care following the Tomlinson review.

The Minister for Health (Dr. Brian Mawhinney) : The Royal Free hospital will continue in its role as an important and well-managed provider of services to local patients.

Ms Jackson : Does that mean that the recommendations of the London implementation group specialty reviews will not be implemented? Under those recommendations, the Royal Free would lose cancer treatment, neurosurgery, paediatrics and a world-renowned renal transplant unit. Are not the review boards, brought into being by the Department of Health, yet another smokescreen put up by the Government in an attempt to conceal the basic fault in their policy, which is that a market economy cannot provide the health service that the country demands and should receive?

Dr. Mawhinney : Of course they are not. As the hon. Lady knows, the specialty review reports represent independent advice to Ministers and they will not determine--by themselves, certainly--the future pattern of services. The recommendations as they affect the Royal Free will no doubt be a subject for discussion with the region, with local hospitals and with the implementation group, to ensure that all points are properly satisfied. That is what my right hon. Friend the Secretary of State told the hon. Lady on 23 June and I confirm it.

Mr. Tracey : Does my hon. Friend agree that we can all go on about our own local hospitals and that I could make a strong case for more resources for Kingston hospital, but that our policy is about universal health care across the whole of London and our first priority must be primary care across London?

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