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Mr. Deputy Speaker : Again, the hon. Gentleman knows the answer to that. The hon. Gentleman who has the floor is responsible for his own speech.

Mr. Dobson : In the past four years, one in five of London's accident and emergency units have been closed. Now accident and emergency services are threatened at Bart's and Guy's, St. Andrew's hospital at Bow, Harold Wood hospital, Queen Mary's Roehampton and the West Middlesex hospital.

Several hon. Members rose

Mr. Dobson : My hon. Friend the Member for Dulwich (Ms Jowell) made a series of visits to accident and emergency departments. She has been told by the staff that things are getting worse, and what they need most is better access to in-patient beds.

Everyone has heard of patients being kept on trolleys all night, but at Bart's last December, they did not just run out of beds : they ran out of trolleys. They had to dump an unconscious man on a mattress on the floor. On another occasion, to provide an intensive care bed for man brought in with gunshot wounds, Bart's had to unyoke an existing patient from his life -support machine and, because there were no beds at Bart's, he was transferred by ambulance to the Homerton hospital.

That is just one accident and emergency department, but such incidents are taking place all over the place. Some people dismiss these stories as anecdotes, but London knows that it is really happening.

Several hon. Members rose

Mr. Dobson : I shall give way to the hon. Member for Colchester, North (Mr. Jenkin).

Mr. Bernard Jenkin (Colchester, North) : I remind the hon. Gentleman that it was the last Labour Government who set up a working party to look into resource allocation, thus recognising that London had become over- provided. It may be that London is over-hospitalled, and we agree that it is under-resourced for general practices. But what are the hon. Gentleman's policies ? He seems to be advocating the provision of mountains of extra cash for the health service in London. It is

Mr. Deputy Speaker : Order. Interventions are supposed to be brief. This is an emotional debate, but

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Members on all sides will get a fair hearing. If it is obvious that an hon. Member is not prepared to give way, others must resume their seats.

Mr. Dobson : Then there is the deplorable state of the London ambulance service, which is by far the worst in Britain, falling far short of its performance targets. Ninety-five per cent. of 999 calls should be responded to within three minutes ; in London, that is managed in only one third of cases. Half of all emergency ambulances should arrive within eight minutes ; in London the proportion is only one in eight. Ninety-five per cent. should arrive in 14 minutes ; in London this is managed in only two thirds of cases.

Let us be clear about the fact that people suffer as a result of these slow responses. Some suffer avoidable permanent pain or disability. Others die while waiting for an ambulance, while on the way to hospital or after arrival.

The Government say that all this rundown is necessary and just, and that it enables them to invest more in primary care. It is clear that more funds are needed for primary care in London, which, according to the Government's own figures, is under-funded compared with the rest of the country.

There are two flaws in the Government's argument. The first is that, in the period during which they have been claiming to shift funds into primary care, the number of general practitioners in London has actually gone down- -and so, we believe, have the numbers of health visitors and district nurses. There has, however, been a 32 per cent. increase in the number of managers in the zones specially targeted for more funds.

The other fault lies in the Government's argument that more investment in primary care will reduce demand for hospital care. There is no evidence to back this claim. Indeed, common sense suggests quite the reverse. If more people can see a doctor, more are likely to be referred for treatment in hospital.

The idea of reducing the number of hospital beds in London to help general practitioners is not supported by GPs themselves. A poll of London's GPs showed that two thirds of them believe that the Government's proposals for health care in the capital will be detrimental to their patients. One third called for more funding for hospitals to increase the availability of beds, thereby enabling them to improve the quality of care for their patients. Like accident and emergency staff, they saw bed shortages as a major problem. How can all this be going on if, as the Government claim, they are putting more funds into the NHS ? For a start, the increase in London has been less than one third of the notional increase in the rest of the country. But that is only part of the story. So much NHS funding is now being wasted. Vast amounts are consumed, to no one's benefit, by the new bureaucracy needed to implement the Government's reforms. In the four Thames regions, while the number of nurses has been reduced by 5,000, the number of management staff has risen by 5, 700--nurses down by 5 per cent., managers up by 16 per cent ; and managers are paid a great deal more than nurses.

This sort of change is an inevitable consequence of the new way of running the health service. Everyone predicted that it would lead to more bureaucracy, more paper pushing, more billing and debt collecting--and it has. As a result, the proportion of NHS funds spent on

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administration now exceeds 10 per cent. Ten years ago, predecessors of the current Ministers boasted that the figure was under 5 per cent. What a brilliant reform : doubling the spending on paperwork. But this is not the only waste of money that has developed under the Conservative Government. Hundreds of millions of pounds has been spent on management consultants, public relations consultants, lobbyists--a whole rag-bag of Porsche drivers receiving outdoor relief at the expense of the patients.

Just recently, timed to coincide with the local elections, the Secretary of State issued a misleading leaflet about the health service in London. It has cost the taxpayer more than £250,000, and that amount should really be included in the election expenses of every Tory candidate in London. However, it is such a stupid leaflet that it probably did more harm than good. On top of that, the Department of Health now employs a good news unit, which spends its time plaintively ringing health authorities and trusts asking them to come up with good news on the NHS which Ministers can use. Can the Secretary of State tell us what the people in that unit will be doing during the local and Euro-elections ? Have they been redeployed into useful work, or are they still deployed producing good news stories for Ministers during the election period ? I will give way to the right hon. Lady if she wants to tell the House about that. In parallel with that effort to promote favourable stories, the Government have tried to gag people working in the NHS to stop them revealing what is going on.

Another problem for the Government arises from their curious abandonment of the basic ideas at the heart of conservatism--with a small c. A real Conservative believes in letting well alone, not going for change unless the benefits of the outcome of that change would clearly exceed the bother and expense involved in the process. The Government's approach to the NHS, with its endless changes, owes more to the theories of Trotsky on permanent revolution or Chairman Mao on the cultural revolution than ever it did to Edmund Burke or Adam Smith.

The constant process of change in the NHS consumes an enormous amount of money, time and effort among those who are involved. It distracts them from doing their job of looking after patients, and consumes funds which could be spent on patient care.

Several hon. Members rose

Mr. Dobson : I shall certainly not give way to hon. Members who will raise spurious points of order, so that rules out a fair number, but I shall give way to the hon. Member for Harlow (Mr. Hayes).

Mr. Jerry Hayes (Harlow) : I have a simple question for the hon. Gentleman. Why on earth is he here ? Is it to paper over the cracks because the Labour party has no policy at all on health, or is it because the Leader of the Opposition has no confidence whatever in the shadow spokesman on health ? It is clear that the national health service would not be safe in the hands of the hon. Member for Sheffield, Brightside (Mr. Blunkett).

Mr. Dobson : It seems that spurious interventions have succeeded spurious points of order.

I have spoken about wasting funds, and I shall give an example from my constituency. University College

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hospital is on a good site, with the best possible access for emergencies, as the Secretary of State has confirmed. Over the past decade, under Government pressure, the hospital management has been forced to investigate the possibility of moving to no fewer than 12 sites, ranging from : on top of Euston station, to next to Great Ormond street, to Camden lock, and to knocking over Elizabeth Garrett Anderson hospital and building UCH there instead.

Money was spent on advice from consultants, architects, engineers and God knows who else, but no one has come up with an idea better than leaving UCH where it is. All that has cost a fortune, and it is the sort of thing that has been going on all over London. It is another terrible waste.

Mr. Harry Greenway (Ealing, North) : Will the hon. Gentleman give way ?

Mr. Dobson : Not at the moment, but I shall shortly give way to the hon. Gentleman.

Of course, there is a fatal flaw at the heart of the Government's changes to the NHS : the introduction of what they call an internal market. That is based on the absurd proposition that health care is unique and that what is cheapest will also be the best. That is not true of a pair of shoes, a pair of jeans or a hotel.

If we decide to buy a cheap pair of shoes, we know that they will not be the best pair of shoes, but the Government want health authorities to place contracts with the cheapest hospitals rather than with the more expensive ones. But, as everybody knows, in many cases the more expensive hospitals provide better treatment. Heart bypass operations at one London teaching hospital may involve the death of one patient in 100. At other hospitals the death rate may be as high as four or five patients in 100, and the same applies in other specialties.

What right have Ministers and accountants to intervene and send patients to hospitals that are not the first choice of either the patient or the GP, and which both know are not as good ? That also breaks another promise made by the Chancellor of the Exchequer in 1990.

Mr. Harry Greenway : Is the hon. Gentleman aware that, in 1987, the then Labour-controlled Ealing council put up rates on Ealing hospital by £330,000 ? That could have provided a lot of treatment for my constituents and the people of Ealing, but the council did not care. What does the hon. Gentleman think ? He does not care either, when it really comes to it.

Mr. Dobson : Apparently, we have the self-answering question from the hon. Gentleman. If he wants to talk about Ealing, he might bear in mind for a moment the fact that hospital staff living in council houses have seen their rents double ; they are now paying the highest rents in Britain.

But that is not the only problem that results from making hopitals compete for patients. At one time, all the institutions in the NHS used to work together for the benefit of patients. There were some silly rivalries, but they were on the periphery. Today, competition is at the heart of relationships within the NHS. Again, I want to illustrate that with an example from my area.

Following changes in the way that funds are allocated, the Bloomsbury and Islington health authority is set to lose a lot of its funding. All the local NHS managers are agreed on that--at the health authority, the family health services

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authority, University College hospital and the Middlesex, the Royal Free, the Whittington and Elizabeth Garrett Anderson hospital. Together with my hon. Friends the Members for Hampstead and Highgate (Ms Jackson) and for Islington, North (Mr. Corbyn), I met various manangers to discuss the problem. We suggested that all concerned should get together to make representations to the Secretary of State. But the response was, "Oh, there's no chance of that. It's dog eat dog now in the NHS"--dog eat dog, in what used to be a national health service.

Supporters of the Government's policies can come out with all sorts of management blather about performance indicators and the like, but the instincts of Londoners are sound. They like their local hospitals. They take pride in the great teaching hospitals that have successfully combined service to local people with training doctors and nurses, and research and developments in treatment that have made them famous around the world.

Londoners are proud of London's hospitals, be it the Royal Free, the first free hospital, originally the London general institution for the gratuitous care of malignant diseases, or the Royal Marsden, the first to provide free cancer treatment for poor people, or the Brompton, the first to admit poor people suffering from tuberculosis.

Some time ago, when defending her efforts to close Bart's, the Secretary of State said that she was not responsible for the national heritage. Well, Londoners think that she is. Bart's was founded in the year 1123. It is part of our national heritage. It has been doing something useful for London for more than 800 years. It has been there longer than there has been a Parliament.

Bart's had been open for 400 years before Tyndale's English bible was first published. The Secretary of State may not want to do so now, but will she, in the quiet watches of the night, ponder whether she, who has not held her office for 800 days, should wipe out a hospital that has served Londoners well for 800 years ?

This is make or break time for London's health services. Hospitals once closed will be hard, if not impossible, to reopen. Expert operating theatre teams once dispersed would be difficult, if not impossible, to bring back. Therefore, I implore the Secretary of State to go back to the Cabinet and to say,"We've got it wrong. We need to look at this again. We've got to make a fresh start. We must put the interests of Londoners before the interests of bureaucrats." If the Secretary of State will not do that, Londoners will never forgive her. That is why Labour is calling for a freeze on all bed and hospital closures, and a genuine and open review of what must be done. Londoners need a health care system fit to meet the challenge of the 21st century, and the cuts must stop before it is too late. 4.44 pm

The Secretary of State for Health (Mrs. Virginia Bottomley) : I beg to move, to leave out from "House" to the end of the Question and to add instead thereof :

noting the rapid advance of medical science, population migration from Inner London and the increase in provision of specialist services outside the Capital, believes that the National Health Service must respond to these changes ; congratulates the first government in 100 years prepared to tackle these issues ; believes that the Government's long-term programme of strategic change is already leading to better services for patients, especially

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better primary care, and will strengthen centres of excellence in teaching and research and lead to a more sensible use of resources ; and condemns her Majesty's Opposition for cynically treating the National Health Service in London as a party political battleground regardless of the interests of either staff or patients.'. If ever there was a case for the pamphlet that we have produced on the NHS changes in London, the hon. Member for Holborn and St. Pancras (Mr. Dobson) has just made it, although I fear that it must have been too complicated for him because his total ignorance, lack of understanding and deplorable, mischievous statements show that he needs an intensive programme of training and education. All that he could do in the end was to call for a 2lst report into the problems of London--the 21st in the last 80 years.

The changes that confront the health service in London are necessary if patient services are to be improved. The changes are complex. They involve not just the health service but medical education and research, and they are long overdue. They do not lend themselves to the sort of soundbite cynicism that we have just heard from the hon. Gentleman.

Londoners deserve to know about the changes and why they have to happen. They do not need Labour's rants, riddled with inaccuracies, distortions and error. The hon. Gentleman's speech was typical of the Labour party's style. Labour Members provoke fear rather than inspire understanding ; they are not interested in running the health service only in running it down ; they are long on rhetoric, short on fact and devoid of understanding.

The hon. Gentleman brought to the debate all the wisdom and insight on health that one would expect from a spokesman on transport. The hon. Member for Sheffield, Brightside (Mr. Blunkett) has been forced to listen from the substitutes' bench. He has been binned in order to give his hon. Friend the Member for Holborn and St. Pancras a bit of pre-election lebensraum.

Earlier this week the hon. Member for Brightside asked about my position. It seems that he has now fled the field. He is the victim of a soft shoe reshuffle. We know, however, what the Labour party is up to. It is not interested in a debate about health ; all it wants is a chance to boost its miserable campaign for the London elections. That is why the hon. Member for Holborn and St. Pancras opened the debate. He, after all, is its campaign cheerleader, a job he got, we recall, as a consolation prize for coming second to the hon. Member for Kingston upon Hull, East (Mr. Prescott) in the beauty contest. That speaks volumes for the Labour party's attitude.

Dame Elaine Kellett-Bowman (Lancaster) : Does my right hon. Friend agree that it may well be that the hon. Member for Sheffield, Brightside (Mr. Blunkett) did not dare put his nose here because he knows perfectly well that the north wants its fair share of resources ? He dare not come here and yell that he wants more for London.

Mrs. Bottomley : My hon. Friend has it exactly right. What is more, the statements of the hon. Member for Brightside are already far too committed to the need for change so he had to be shuffled off before the debate took place.

Mrs. Bridget Prentice (Lewisham, East) : Will the Secretary of State tell the House when she last came to the Dispatch Box voluntarily and initiated a debate on health in London or elsewhere in the country ?

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Mrs. Bottomley : I should like to know when the hon. Lady last spoke to the House about the £25 million going into her local hospital. Somehow, Lewisham hospital is not mentioned in the House. That hospital is receiving enormous investment and showing great change and improvement.

Ms Joan Ruddock (Lewisham, Deptford) : Can the Secretary of State tell my constituents and those of my hon. Friend the Member for Lewisham, East (Ms Prentice) how their health services are to be improved as she suggests when the hospital on which many of them depend, Guy's, is to lose a minimum of 400 beds which are currently in use, and an accident and emergency department, and why at Lewisham hospital her accountants have created a situation whereby there are to be 70 compulsory redundancies, and highly skilled nurses are to be replaced by care assistants ?

Mrs. Bottomley : The Labour party wilfully chooses to fail to consider the whole point because it considers only institutions. In the constituency of the hon. Member for Lewisham, Deptford (Ms Ruddock), in Southwark, Lambeth and in Lewisham, there are 200 primary care projects going ahead in the next five years. The hon. Member for Holborn and St. Pancras (Mr. Dobson) has 72 general practitioners in his constituency. Did we hear about the deprivation payments that they now receive--up to £30,000 for each GP in the hon. Gentleman's constituency ? No, because, he, like the rest of the Labour party, voted against the new GP contracts. Did we hear that now 90 per cent. of children are immunised in the hon. Gentleman's constituency, as in the constituency of the hon. Member for Deptford ? That figure used to be 70 per cent. before the new GP contracts and the Labour party voted against it. The Labour party is so obsessed with institutions because they are centres of the health unions. Every one of the Opposition health spokesmen is sponsored by one of the health trade unions. They do not want to undermine their power base. They do not speak for patients. They speak for the provider interests.

I must say that change is necessary in London and I hope to set out in greater length why that change is necessary. The outrage Several hon. Members rose

Mr. Deputy Speaker : Order. The Chair hopes to be able to hear what the Secretary of State has to say-- [Interruption.] Order. I address my remarks to both sides of the House.

Mrs. Bottomley : I suspect that I have already given way a great deal more than the hon. Member for Holborn and St. Pancras. It is my natural instinct, when seeing such a blinkered ignorance, to wish to respond, but I understand that many Conservative Members are impatient for change, recognise the need for it and want to catch your eye, Mr. Deputy Speaker.

The debate is of great importance to London and to Londoners. Instead of a bona fide health spokesman, we get the performing political monkey. It insults Londoners, it insults their health service and it insults everyone working in that health service. So did the shameless behaviour of the right hon. and learned Member for Monklands, East (Mr. Smith), who wished to visit Bart's

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this morning, did not even have the courtesy to inform the local Member of Parliament, then wished only to go if he could go in a media circus. [ Interruption. ]

Mr. Deputy Speaker : Order. The House must settle down.

Mrs. Bottomley : It is the last Opposition day debate before the local elections. Those local elections concern housing, education, social services and transport. What does the Labour party choose to speak about ? It chooses to speak not about the subject of those local elections--the fact is that it wants to conceal the performance of its local councillors-- but about a subject which it always tries to wheel out every time it wants to raise its profile : exploiting the health service and wilfully misrepresenting the situation.

Dame Elaine Kellett-Bowman : Like Jennifer's ear.

Mrs. Bottomley : Like Jennifer's ear, as so many of my hon. Friends have said. The Labour party does not have a policy for the NHS in London that goes beyond next Thursday. Labour Members do not understand that Governments must measure their responsibilities in years and decades. Government responsibility is to patients and to the NHS staff who work for patients. Our responsibility to patients means that we have to look to health care in the future, rather than preserving, unchanged, every institution that has served us in the past. Our responsibility to staff means that we have to explain to them the need for change and help them to meet it. We have to reduce pressure on staff. No Government have done more than this one to reduce the unacceptably long hours worked by junior hospital doctors, ably helped by leaders of the Junior Hospital Doctors organisation from time to time and on which we have now spent £115 million. We have set up a clearing house to help staff in London who are affected by the changes to get new jobs.

First and foremost, our commitment must be to patients and I give an absolute commitment that services in London will change only for the better. Patients will receive more care, better care and closer to their homes. Professional staff will have the chance to respond to change, to provide care in different settings and to work in the NHS of the future. The health of London and of Londoners will steadily continue to improve.

Anyone who has studied those matters in detail--it is already clear that the hon. Member for Holborn and St. Pancras has seen very little and studied very little--knows that some of the needs for change go back 100 years. The hon. Gentleman and others have quoted Professor Jarman of St. Mary's hospital. I shall quote Professor Nick Bosanquet, who said that we must face change. He said :

"London health services may have had a glorious past but their quality in the future depends on our willingness to face up to difficult choices now."

The Labour party has not shown a willingness to face any difficult choice at all.

Mr. Dobson : Just to correct the Secretary the State, I never mentioned Professor Jarman. If the right hon. Lady were to suggest that I have personally opposed changes in health services in my area, that would be a lie, because I was one of the first to suggest the amalgamation of the Middlesex and University College hospitals. When the North East Thames regional health authority said that it was ridiculous to have two regional cancer centres in my

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constituency, I agreed with it and believed that it was right that they should be transferred elsewhere. In the Labour party, we say yes, there needs to be change in the health service in London, but the changes that the Government are putting forward are the wrong changes.

Mrs. Bottomley : The hon. Gentleman fails to recognise that it is his health authority, in trying to assess the need of the local population, which is so anxious to put more resources not into hospitals but into the community--for example, an extra £500,000 into mental health services. That is why the authority wants to compare the costs of different hospitals, because if it gets better value for treating local patients, it can invest in further care. It is in the hon. Gentleman's constituency that I visited one of the most outstanding centres for people who have been resettled from Friern in Camden road. That is a multi-million pound project. There are a whole range of initiatives to help local people.

Mr. Brian Sedgemore (Hackney, South and Shoreditch) : The Secretary of State has a degree in sociology. That is the problem.

Mrs. Bottomley : I am grateful for the hon. Gentleman's intervention because he rightly says that I have a degree in sociology. I have two degrees in sociology--[ Interruption. ].

Mr. Sedgemore : That is the problem. [ Laughter .]

Mr. Deputy Speaker : Order. May we have a little quiet below the Gangway ?

Mrs. Bottomley : It is because I have two degrees in sociology that I believe that the way forward is to assess the local health need, not to allow policy to be dominated by the interest of the institutions--respected and loved though they have been--but to start from the interests of patients, from their health concerns and their social concerns, which Labour Members profess to support. Always, however, they resile from the analysis, they duck the difficult decision and take the populist way forward. They are interested not in patients or in staff but only in buildings.

It is no matter to Labour Members that there are 18 major hospitals in an area of central London where the population has fallen by 1 million in the past 30 years. It is no matter to them that there is duplication and fragmentation of specialist services, which weakens our medical excellence, splitting it between a plethora of different sites. It is no matter to them that GP services across the capital and services for the mentally ill have suffered decades of neglect, while the money has gone to support duplication in central London. We can agree that there should be more primary care in London, but what the Labour party will not recognise is that if we are to invest more and more in primary care, we have to unlock the resources which are tied up in the battalion of big hospitals in central London.

Mr. Andrew Rowe (Mid-Kent) : Before my right hon. Friend gets on to the subject of primary care, does not she agree that the hon. Member for Holborn and St. Pancras (Mr. Dobson) made her point for her when he pointed out that the cost of providing health care in London is far higher than elsewhere in the country ? To go on sucking

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patients out of constituencies such as mine into London quite unnecessarily is a gross misuse of national health service funds.

Mrs. Bottomley : My hon. Friend is exactly right. The average cost of a London teaching hospital is 46 per cent. above the cost of a teaching hospital outside London. That money has to be paid, but could otherwise be spent on providing services more cost effectively elsewhere. The Labour party ignores the extra length of stay of patients in London. It also ignores the way in which the population in London has left the centre and gone out to the suburbs. I know that many of my hon. Friends will be pressing to ensure that we make swift progress because they want a fairer distribution of resources. It also ignores the great network of hospitals that has built up around the home counties.

The Labour party not only shows ignorance about all of that, but disregards medical advances. For example, patients who previously had to be treated in hospital, perhaps for several days, even weeks, can now be treated as day cases and there are new diagnostic techniques, even in the community. All that means change. The Labour party may fail to understand that, but why has the number of hospital beds been falling for years in France, Germany the USA--all of which belong to the Organisation for Economic Co-operation and Development ? The distribution of resources means a subsidy this year of £105 million, paid to support the hospitals in central London. If we do not act now, that subsidy will increase and will be needed year after year without improving services to patients. As my hon. Friend the Member for Mid-Ken (Mr. Rowe) rightly reminded me, it is the constituencies outside London that have to pay that bill.

Of course, that is only part of the picture. The subsidy is also paid for in investment forgone elsewhere in the capital. It could be better spent on more GP services, health centres, community nursing, care in the community and all the other local services that are vital to a comprehensive NHS. The Labour party, in effect, wants to sacrifice primary care to preserve each and every institution for all time. That policy is financially irresponsible and clinically illiterate, and Conservative Members will have nothing to do with it.

Mr. Simon Hughes (Southwark and Bermondsey) : I ask the Secretary of State a simple question. Does she accept that the cost of providing public services in the capital, by definition, is higher per capita than elsewhere, because the land cost is higher, salaries are sometimes higher and the incidence of deprivation in the London boroughs is considerably higher than in any other conurbation in the country ? Does she accept that health care in London will always cost more and that, unless she is to ship all patients out of London, she will have to find the money for that additional cost ?

Mrs. Bottomley : I accept that there are special needs in London ; I particularly accept the need to invest in primary care in London. I do not accept, and if the hon. Gentleman is sincere, I doubt whether he does, the need, in the area where his constituency is, for four cardiac units within six miles, each beneath the size recommended by the specialty review. It makes no sense.

Mr. Hughes : Answer the question.

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Mrs. Bottomley : I have answered the hon. Gentleman by saying that I accept that there will continue to need to be special support in London, but I am explaining to him, and to the Labour party, why some of the excessive and unnecessary costs in London have been the result of the duplication of specialist centres. One cannot have a cardiac centre at King's, Guy's, St. Thomas's and the Brook. It makes no sense and does not even provide the best research excellence. It certainly does not produce the most cost-effective care. Not only are there four cardiac centres in that small space, but half a dozen are within easy travelling time. Other Conservative Members will be appalled to think that there was such a duplication of cardiac investment, just to take one of a great number of examples, in such a small space. It is not cost-effective or clinically effective, and it undermines the ability to compete internationally in centres of research and teaching.

Several hon. Members rose

Mrs. Bottomley : In a moment.

The Labour party fails to understand that, as part of those changes, there is also a new £5.3 million cardiothoracic unit at Brighton--the residents used to have to travel all the way to central London for their cardiac care--which is part of the £35 million Royal Sussex hospital. That need for change, so that we have a better balance of specialty services, concentrated in specialty teams, underlines the need for change that has been recognised time and again.

The hon. Member for Holborn and St. Pancras showed a complete lack of understanding about the way in which health services are funded in London. I do not believe that it was a deliberate misreading of the information. I cannot believe that he saw the parliamentary answers to my hon. Friends the Members for Worcester (Mr. Luff) or for Croydon, North-East (Mr. Congdon). Let me make it clear. Health spending in inner London amounts to £553 per head--46 per cent. above the national average. Including the former special health authorities, spending per head in London is 56 per cent. above the norm. Inner London has more acute beds per person than the rest of the country, twice as many consultants and, as I have said, the costs are much higher--46 per cent. more to be treated in one of the teaching hospitals.

The amount of funding available for the health service will always be finite. The Labour party, which always promises the moon and delivers nothing, should be the first to know. My right hon. Friend the Prime Minister reminded the House of its deplorable catalogue when it was in power and responsible for the health service. We have to look to the way in which resources can most effectively be used. We do not resort to the constant denigration of people involved in health service management. To deliver change, support staff and plan buildings requires good management. Leading clinicians should be involved in clinical work. To denigrate one part of the service rather than the other is deplorable.

Mr. John Gorst (Hendon, North) : I fully understand the logic behind the medical and financial criteria to which my right hon. Friend is referring. However, where a closure is proposed--the proposal might not yet have come to her level, but consultation is taking place--if there are strong social reasons for keeping a hospital open, is it possible that she might overrule financial and medical grounds ?

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Mrs. Bottomley : In every case, careful consultation takes place, and has to take place. Certainly, it is not only narrow issues of value for money which weigh ; it is looking for best value, best clinical outcomes and the interests of patients. Where a population feels very strongly about local provision, that must be strongly considered.

Mr. Toby Jessel (Twickenham) : My right hon. Friend earlier mentioned suburbs. As two thirds of London's population lives in outer London, did she notice that, although the hon. Member for Holborn and St. Pancras (Mr. Dobson), the Opposition spokesman on Transport, might know about transport, his sense of geography is a little odd, as he scarcely mentioned outer London at all, and practically the whole of his speech was on inner London ? Is she aware that, in my constituency, there are four new GP surgeries, which people are very pleased with, and that people in outer London happen sometimes to fall ill as well and might need some service there, too ?

Mrs. Bottomley : I thank my hon. Friend for making that point clearly. He does his homework and understands the situation in his constituency, unlike many other hon. Members.

There has been, rightly and properly, discussion of accident and emergency services. I suppose that a spokesman on transport could be allowed to have views that should be considered when it comes to ambulance services. He failed to remind the House, however, that this year we put an extra £14.8 million into the London ambulance service. That follows the figure of some £7 million for last year. The hon. Member for Holborn and St. Pancras is right to say that we have been far from satisfied by the performance that is being achieved by the London ambulance service. Indeed, my hon. Friend the Under-Secretary is, at this moment, with the London ambulance service, on a visit to one of its vehicles, but, unlike the Leader of the Opposition, he did not feel the need to summon up the television cameras to follow him on that visit. He regards it as part of his responsibilities to know what is going on. He does not feel that the visit would be wasted if he does not have a whole television crew pursuing him.

Not only has the extra money resulted in a new fleet with 120 more ambulances. Above all, when it comes to what our constituents need in accident and emergency services, we have gone from 300 to 400 paramedics since about the time of the last local elections in London. Having gone from 300 to 400, we are on line to reach 1,000 paramedics on those London ambulances by 1996.

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