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Mr. Jessel : Did not the hon. Gentleman hear the clear and obviously sound arguments from my hon. Friend the Member for Broxbourne (Mrs. Roe) that the sheer number of beds should no longer be seen as a sensible yardstick of the amount of care that has been provided ? He is carrying on with his speech as if my hon. Friend had not said that.

Mr. Austin-Walker : I do not disagree that modern techniques and improvements in care may mean that some patients will stay in hospital for shorter periods and that that will increase the ability for a throughput of patients.

I would point out, however, that 165,000 people on waiting lists in London are waiting to get into hospital. Reducing the number of beds does not seem to be a sensible way to get the list down. The problem is not that the beds are not being used ; they are being used where the funds for nursing and support staff are available.

Particular problems face the health care and health district of Greenwich. The Greenwich healthcare trust is operating with reduced resources this year because it is gaining fewer contracts. That is partly because of the trend that some areas that used to purchase from it are now purchasing locally, but also because of the compliance with the requirements on junior doctor hours, that require the healthcare trust to reduce its operating costs.

The calculations that the local healthcare trust is making for the future are based on the possible availability in the near future of the Queen Elizabeth military hospital. I ask the Minister to address the serious problem which now

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faces Greenwich health authority and the Greenwich healthcare trust. There is still some uncertainty about when the Queen Elizabeth military hospital will be available--if at all--to the national health service and the terms on which it may come over. The health care needs of residents of Woolwich, Greenwich and Eltham will suffer severely if the Brook hospital closes without the Queen Elizabeth military hospital coming on stream to replace it. There is, therefore, an urgent need for decisions by the Department of Health and Ministry of Defence on the future of the Queen Elizabeth military hospital. A number of urgent planning decisions need to be taken. The Secretary of State said that Opposition Members had made very little reference to the increased investment in primary care. I acknowledge that there is to be substantial increased investment in primary care in the Greenwich waterfront in Greenwich and Woolwich. I welcome that investment in primary care, but it is taking place in isolation from any consideration of its relationship to the provision of acute services in the area and the acute services review strategy.

One issue on which we would question the Government policy is that the Secretary of State's policy is based on the premise that London is ill- provided for in terms of primary care and that improvements in primary care will reduce the need for hospital beds and admissions. I am not aware of any evidence from any western country or from anywhere in the world that shows that improvements in primary care reduce the demand on hospital services.

All those who gave evidence to the London health inquiry, including the chair of the local medical committee, made a clear statement that improvements in primary care and access to it lead to increased, not fewer, demands on hospital services. It seems, therefore, that the Government are operating on a wrong premise.

In support of that I would adduce the recent comments of the Parliamentary Office of Science and Technology which suggest that improvements in screening and primary care will lead to extra nursing time, extra medical time, extra staff, extra in-patient days, extra out-patient visits and tertiary referrals to specialist centres. Many of the specialist centres in London are under threat by the Government review.

Will the Minister respond to the point made by Professor Sir Colin Dollery, that the Government's reorganisation of specialist units does not take any account of the possible capital costs of that relocation, which he has estimated at £1 billion ?

It is not true, as the Secretary of State suggested, that Opposition Members have a total preoccupation with acute services and beds. I draw attention to the crisis in mental health in the capital city. The Mental Health Act Commission's report published in 1993 drew attention to crisis in inner city mental health services, including London. It stated :

"Implementation of section 117 Aftercare and the Care Programme Approach"

that is the section of the Mental Health Act 1983 under which patients detained have a right to aftercare on discharge from hospital

"is barely evident in many inner city acute units. The high morbidity levels in the inner city populations, lack of alternatives to admission, problems of homelessness and poor community service, are contributing factors to the crisis in inner city mental health services".

It is important that we address those issues.

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The report of the inquiry into the care and treatment of Christopher Clunis, the Ritchie report, published in February 1994 specifies the high--more than 100 per cent.--bed occupancy rates in London's psychiatric units and the lack of supported accommodation. Those issues require the Government's urgent attention.

The House of Commons Health Committee report "Better Off in the Community" also referred to serious problems in mental health services in London. It expressed concern about the situation in some inner cities areas and contradictions in Government policy in the areas of health, housing and social security and identified the increased demands on mental health services which arise from social deprivation. That is a serious issue for most inner London boroughs and for some of the outer London boroughs as well, such as Newham, Haringey and others with a similar social make-up. The resource allocation formula needs to be reviewed to reflect that link. The high level of homelessness affects the health service needs of the population of London. It does so in the sphere of mental health no less than elsewhere. The report of the Select Committee on Health pointed out the need for the allocation of resources specifically for housing. It identified the funding impasse that is preventing the development of permanent supported accommodation for homeless people with mental health problems who are living on the streets of London. The Government must address this matter urgently.

It has been suggested on a number of occasions that primary care and preventive measures may reduce the need for hospital beds. There is one way in which, in the long term, the need for beds could be substantially reduced. I refer to the fact that on Friday 13 May the Government could support the Bill being introduced by my hon. Friend the Member for Rother Valley (Mr. Barron) to ban tobacco advertising. The Government may argue that the bulk of tobacco advertising is aimed at persuading people to switch brands, but it is clearly a fact that between 100 and 150 people a day die as a result of cigarette smoking. One of the principal aims of tobacco advertising is to recruit teenagers to replace the smokers who have died. In London, the problem of tobacco-related illness is as great as anywhere else in the country.

I want to mention briefly the question of the environment, although I realise that some of my hon. Friends, if they catch your eye, Mr. Deputy Speaker, intend to talk about environmental problems in London. I shall refer specifically to air pollution. The part of London that includes my constituency and that of the hon. Member for Eltham (Mr. Bottomley) has one of the highest rates of asthma and respiratory illness in the country. We suffer from poor air quality. The Government's failure to tackle the problem of air pollution accounts for a major part of the demand on health care resources in the capital city. Their policies on health cannot be divorced from their policies on issues such as transport. In transport terms, but also in health care terms, it makes absolutely no sense for the Government to press ahead with their ludicrous programme of road building in south-east London, which will have such a detrimental effect on the health of the population.

My last point concerns the London ambulance service. Before becoming a Member of Parliament, I was responsible for introducing a report published by the Association of London Authorities on the crisis in the London ambulance service. That report pointed out many

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of the problems that the service faced at the time. The then Secretary of State for Health--now the Chancellor of the Duchy of Lancaster--dismissed it and accused us of merely being the mouthpiece of the trade unions. If the right hon. Gentleman had listened to the Association of London Authorities when he was Secretary of State for Health, we would not have the crisis that we are facing today. I realise that the current Secretary of State has taken a personal interest since the computer went down and the London ambulance service crashed, but the most recent evidence is that since the right hon. Lady's intervention there has been no improvement in the service's response time. This is one of the most serious issues. It demonstrates that there is no strategic authority for London to plan ambulance services and that there is no system of accountability. Opposition Members not only insist that there should be a moratorium on the cuts and closures in health services in London, but argue for a system of accountability in respect of those services.

6.43 pm

Mr. Tim Yeo (Suffolk, South) : I am glad of the opportunity to contribute to the debate from the Back Benches. The subject is of deep interest not only to Londoners but to millions of people outside the capital, including many in my constituency. That is so not least because of the possibility--to put it no higher--that the perpetuation of a pattern of health provision in London that is not adapted to meet contemporary needs will pre-empt resources that could be used elsewhere in the national health service.

Before coming to the substance of that argument, I should like to take issue with the hon. Member for Southwark and Bermondsey (Mr. Hughes), who said that my right hon. Friend the Secretary of State was mistaken in spending time on an exploration of the reasons for the absence of the hon. Member for Sheffield, Brightside (Mr. Blunkett). It is of interest and concern to the House that, on a day on which the Opposition have an opportunity to choose the subject for debate, their principal spokesman on health should have decided to absent himself.

However, I can probably throw some light on the matter. My hon. Friends and I have come to realise that, after two years of mouthing slogans dreamt up by his trade union paymasters, the only achievements to the credit of the hon. Member for Brightside are, first, the removal of any lingering doubts about the wisdom and merits of the Government's national health service reforms and, secondly--and more surprisingly--the fact that he may have produced nostalgia and even affection among Conservative Members for the days when the Opposition's health spokesman was the hon. Member for Livingston (Mr. Cook).

However, all is not lost for the hon. Member for Brightside. The Opposition made an inspired choice in asking the hon. Member for Holborn and St. Pancras (Mr. Dobson) to lead the debate. I believe that the hon. Gentleman is the only Member of Parliament capable of making the hon. Member for Brightside appear to be intelligent, statesmanlike and original. Indeed, his speech was one of the most disgraceful and blatant attempts to exploit a very serious issue for very short-term political

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advantage. If the hon. Gentleman has done anything, it may be to have restored the reputation of his hon. Friend the Member for Brightside.

The two hon. Gentlemen have a common approach. Their speeches on health issues are designed to achieve two things--first, to please their trade union paymasters ; secondly, to inspire as much fear as possible in the minds of patients by spreading misleading scare stories about the Government's health policy. That is matched by their absolute refusal to tackle any questions concerning the allocation of finite resources between competing priorities. Indeed, their determination to duck any remotely hard choice appears to be without limit. Perhaps it is matched only by the similar capacity that the Liberal party so often displays.

Despite the bluster in the opening speech of the hon. Member for Holborn and St. Pancras, in which he rather boastfully said that my hon. Friends to whom he had given way on a previous occasion had all lost their seats

Mr. Dobson : All but one of them.

Mr. Yeo : Sorry--all but one of them. As soon as the hon. Gentleman was confronted with interventions from Conservative Members, who clearly knew a great deal more than he about the health service in London, he refused to give way for further interventions. I want to give him another opportunity to answer a question that he refused to answer earlier. Is it Labour party policy to increase the per capita spending on health in London ? If so, does the party propose to fund the increase by reducing the allocation to other regions or by raising taxation ? If it is the latter, I hope that the hon. Gentleman has cleared the matter with his hon. Friend the shadow Chancellor. I shall gladly give way to him. He failed to answer that question when it was put to him earlier. If he needs to phone his hon. Friend the Member for Brightside, there will probably be time to get an answer.

Mr. Dobson : First, I should like to make it quite clear that my hon. Friend the Member for Sheffield, Brightside (Mr. Blunkett) had a long- standing engagement to address a public health conference in Birmingham and to visit parts of the city, and he asked me to stand in for him. I was delighted to do so as the shadow Cabinet member with responsibility for London. I can reasonably claim at least some connection with the national health service in central London, as I and my family depend on it.

Complaints by Conservative Members about Labour's choice of a debate on health in London to take place in Opposition time are total cant and hypocrisy. The current Secretary of State for Health has not initiated a single parliamentary debate on health since she came to office. Until she does, it does not lie with her to criticise anybody. As I made clear in my speech

Mr. Yeo : Answer the question.

Mr. Dobson : I remember the second part of the question : I am not stupid, as are some Conservative Members. In view of all the money that the Government's reforms are wasting in the health care system in London, a substantial part of any extra funds that are needed to provide services should come from getting rid of most of

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the management consultants, PR consultants and general hangers-on who have been ripping off the health service for donkey's years.

Mr. Yeo : The House will have noted the hon. Gentleman's complete failure to answer my question. He is not even as good as the Liberal party spokesman at ducking the issue. We now have confirmation that Labour party Front-Bench spokesmen plan to have health debates on days when their health service spokesman has long-standing engagements in Birmingham.

Mr. James Clappison (Hertsmere) : That is precisely the point that I was about to make. Does my hon. Friend agree that perhaps the Labour party could do with a few management consultants ?

Mr. Yeo : My hon. Friend makes a most penetrating intervention. The timing of the debate finally blows apart any pretence that the Labour party is genuinely concerned about the health needs of London. It is worried only about making political points and it has timed the debate just one week before the London local elections. That can only be interpreted as a desperate last-minute attempt to divert attention from the ghastly failures of Labour-controlled London local authorities.

Labour-controlled Lambeth borough council is currently collecting less than half the council tax that it should be collecting. Islington has almost £1 billion of debt, which is more than £5,500 per head of population--the worst figure in the country. The Labour-controlled boroughs of Hammersmith, Southwark and Lambeth have more than £64 million in uncollected rents. That is a massive waste of resources which is not only a terrible indictment of the management and administration of those boroughs, but an everyday tragedy because it denies services to the people of those boroughs.

Mr. Corbyn : The hon. Gentleman spoke about Islington. Will he confirm that the vast majority of its debt was approved by Ministers in the Department of the Environment, not by least the hon. Gentleman when he was a Minister in that Department, and that the money was borrowed to build houses and social service and other centres to provide a decent service for the people of that borough ? Should the hon. Gentleman not at least concede that his Government are now preventing boroughs from developing the services that are necessary to assist with community care ?

Mr. Deputy Speaker (Mr. Michael Morris) : Order. We must return to the health service debate.

Mr. Yeo : The matters that I have mentioned greatly affect the residents of those boroughs. I am glad for the on-the-record confirmation that the Department of the Environment does not block Labour-controlled London boroughs from borrowing the money that they need. At least there is a chance that next Thursday London voters will put all that right by returning Conservative local authorities. Meanwhile, we should celebrate the tremendous success and progress of the Government's health service reforms in London and the implementation of their new policies that are specific to London. I warmly congratulate my right hon. Friend the Secretary of State for Health, who is the first holder of the office to address directly the complex problems of the

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pattern of health provision in the capital city. That is a clear example of the Government's willingness to address difficult issues and to introduce policies regardless of their short-term popularity. We want to do what is right for London in the long term. The Secretary of State has correctly identified the critical importance of improving primary health care and community services in London. Without those building blocks, nothing else that we try to do with London's hospitals or the rest of the health service will stand any chance of success. The Secretary of State and the Minister of State have shown great courage in addressing that matter.

For 100 years, reports identifying the problems in London's health service have been discussed, shelved and ignored. At last, we have a Government who are determined to put the situation right. Of course, the task is not easy and the concerns of people with direct experience of the great London hospitals must be respected. That experience may have been accumulated by those who were patients, students, nurses or doctors.

Through my family, I have direct experience of the excellence of the radiotherapy department at Charing Cross hospital. However, none of us should allow personal experience to colour our judgment of what is right for the future of health provision in London. It is easy and tempting to take on the attractive role of championing a great institution, and plenty of people are willing to speak up for individual hospitals. But, from direct experience, even more people have knowledge of the shortcomings and deficiencies of primary health care and community services. Because those concerns are not always as sharply focused and do not relate so directly to premises and institutions, they are not always articulated so loudly and clearly. The Government's analysis is right. All serious analysts of the London scene--and, for a brief period, there was a hope that that might include the Labour party--recognise the need for fundamental and substantial change. Merely because a hospital has a famous history does not mean that it should be preserved for all time in aspic. My hon. Friend the Member for Broxbourne (Mrs. Roe), who is the Chairman of the Select Committee on Health, spoke about the advances in medical treatment which have greatly shortened hospital stays. Nowadays, far fewer people wish to travel to London from the provinces. Patients do not come from constituencies such as mine in the same volume to great London teaching hospitals, because the high-quality care and treatment that was previously available only in London is now far more extensively available and people prefer to be treated much closer to home. As a result, the London hospitals depend far more than ever before on serving the needs of their local populations.

The introduction of the purchaser-provider split has been a huge spur to greater efficiency. It has allowed a rationalisation of resources which in itself can be immensely beneficial. Eleven years ago, when the Great Ormond street special health authority, as it then was, proposed the closure of the Tadworth Court children's hospital, I led a campaign that was backed by the leading voluntary organisations to save the hospital. The proposals that we put to the then Secretary of State for Health and Social Security were accepted and they were a kind of precursor of the NHS trust model. We established the Tadworth Court trust as an independent charity, which I chaired for the first seven

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years of its existence. By refining the services offered by the hospital so that they were more responsive to the needs of what we would now call purchasers--in this case Great Ormond street itself and some of the neighbouring health authorities and, indeed, some local authority social services departments--we were able to increase the use of the facilities at Tadworth, improve the efficiency and, therefore, lower the costs of the services there, and to release a huge amount of surplus assets in the form of land. Those assets were sold for about £15 million, which was available to boost the Great Ormond street capital programme. That is a clear example of how rationalisation, which sometimes seems threatening to people because of its possible consequences, can produce benefits all the way round.

The real test of the Government's health service reforms and their policies for London will be in assessing whether they have achieved the improvements in primary health care that are so badly needed. The resources identified by the Secretary of State for Health that are going to many areas of the London health service, but especially to primary health care, should be used not just to improve the general quality of primary health care, but to raise the calibre and the level of staffing and to extend the present trend of improvements to GP premises. Those are important steps.

The hon. Member for Woolwich (Mr. Austin-Walker), who has briefly left the Chamber, tried to suggest that improvements in primary health care do not affect the demands on hospitals. Nothing could be further from the truth. It is clear that there are excessive demands on the accident and emergency services in a number of London hospitals which are directly attributable to the inadequacy of the primary health care system in those areas.

Alongside the improvements in primary health care, we need to see improvements in the community services, and those will depend on good co- operation between the health authorities and the local authority social service departments, regardless of their political complexion. If we see those improvements, there will also be the prospect of easing some of the pressure on the expensive central London acute hospital beds, because people will be able to be looked after more quickly following treatment in the community.

The Government's analysis of the situation in London is correct. The actions that they have set in motion are also correct. The tragedy is that the Labour party has become so obsessed by politics and votes and by the need to obey the demands of its trade union paymasters, so divorced from the reality of the health needs and the welfare of the patients in London, that it is now unable even to enter into a rational debate on this vital subject.

The way in which the issue is being exploited on the basis of a dishonest and distorted view of the facts presented by the Labour party is deplorable. The hon. Members for Holborn and St. Pancras and for Brightside appear ready to stoop to levels from which even the hon. Member for Livingston might have refrained two years ago. They appear to be conducting some sort of Dutch auction to see how low they will take the standards of debate.

But the voters and the patients will draw their own conclusions. I believe that next week the Labour party will be rejected on a massive scale across London. People will want to back Tory measures to strengthen London's health service.

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7.1 pm

Mr. Jeremy Corbyn (Islington, North) : That was a most interesting contribution from the hon. Member for Suffolk, South (Mr. Yeo). I have often thought that one of the problems of Parliament is the amount of politics that goes on within it. It is quite shocking and deplorable.

Mrs. Bridget Prentice : Something must be done about it.

Mr. Corbyn : My hon. Friend is quite correct. I am not sure what, but something should be done about it.

I am rather looking forward to a speech from one of the London Conservative Members. I believe that there still are some and presumably at some point they will try to speak, but thus far we have heard nothing from them. We have heard Conservative Members from the fringes who have inherited some London people in their constituencies, but nothing yet from a London Conservative Member ; we look forward to that.

I thank my Front-Bench colleagues for choosing today's debate on the London health service. It is an extremely important subject and such an opportunity is welcome. I was particularly amazed by the Secretary of State's contribution. My hon. Friend the Member for Newham, South (Mr. Spearing) and I have worked out the pattern of her speech. It was rather like cracking a cipher. It was written by a committee of six people. They took it in turns to write a paragraph and then started again at the beginning. That is why the speech hopped from subject to subject so many times and kept coming back to where it started.

The debate underlines an extremely serious situation in the health service in London. The Government, who have been in office since 1979, have presided over a large number of hospital closures and wholesale changes in the structure and philosophy of the NHS. From a service that was free at the point of use in 1979, the god of the internal market now controls everything ; there is massive privatisation within the NHS and there are serious problems with morale and the way in which people are employed.

Members of my union, Unison, used to feel that they had secure, if not well -paid, jobs within the NHS. They felt that they were there to contribute to the NHS and they did that with extreme dedication. Many of them now suffer the indignity of their jobs being put out to auction every five years in order to find the lowest bidder as more and more services are contracted out. The responsibility of those people who have given such wonderful service to the NHS has never really been recognised by the Department of Health.

If the Government had not been so arrogant for the first 12 years in office and had stopped to listen to what ambulance drivers, workers, officers and paramedics were telling them about the state of NHS ambulances in London, purchasing, the computer and safety, something would have been done earlier. It took the inspirational work of members of the National Union of Public Employees and the Confederation of Health Service Employees, now in Unison, and my hon. Friend the Member for Newham, South during his many efforts in the House, to expose what was going on in the London ambulance service and eventually, belatedly, reluctantly, the Secretary of State did something about it. We are still not following Orcon standards in London. We are nowhere near reaching those

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standards, and a great deal still needs to be done in the London ambulance service. I give that as just one example of the problems created by the Government's attitude towards the health service in London.

The problem is compounded by the obsessive secrecy surrounding the internal market. I recall a meeting that I had with the former manager of the London ambulance service who, fortunately, saved us all by resigning. I asked him whether he could give me the figures on the costs of vehicles and running the London ambulance service. The answer was that it was a commercial secret. He said that it was commercially confidential information. That was from an NHS manager in an NHS-funded operation, because the service was being prepared for privatisation through contracting out. That is what happens when a service as important as the health service is allowed to be dominated by the internal market.

Many hon. Members have referred to population loss, particularly in inner London, the closure of hospitals and waiting lists. As hon. Members were speaking, I was thinking of the number of hospitals that I have known to be closed during my time as a union official in NUPE since 1975 and as a Member of Parliament since 1983. In my locality, for example, the Royal Northern hospital, a wonderful institution on the Holloway road, the borough's war memorial, has been closed. The first letter that I received from a Minister withdrew the pledge given by his predecessor in 1982 that the closure of the casualty unit at the Royal Northern did not presage the closure of the whole hospital. The first letter that I received from a Minister said that he was sorry, but that was a mistake ; it did presage the closure of the entire hospital. That hospital is now closed and has not been replaced. It has been replaced by one new wing in the Whittington hospital just up the road, with fewer beds than before and a longer waiting list.

It says something for the competence of the Department of Health that the Secretary of State was dispatched to open the Great Northern wing of the Whittington hospital last August. What she did not realise was that she was opening a building that had already been partly closed. She was a bit late. A number of wards had already been taken out of operation as a result of lack of funding.

We have the nonsense in London of 165,000 people waiting for hospital appointments and 22,000 beds recently taken out of operation with an increasing number of beds simply not being used because the money is not there to pay the staff. That is an insult to the people of this capital city.

The Government's solution to the crisis was to set up the Tomlinson inquiry. That could have been a good opportunity for a genuine public inquiry with participation by the people of London--doctors, nurses, consultants, trade unions, community health councils, various health campaigns, bodies representing the elderly, those with disabilities and the homeless ; all could have made a contribution to a serious inquiry into the future structure, funding and quality of care of London's health service. But not a bit of it.

Mr. Spearing : A one-man band.

Mr. Corbyn : Precisely. We had a one-man band and a secretive operation that came out with a report that proposed a further removal of 4,500 beds and which, as we speak, casts a shadow over the future of a further 16

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hospitals. There has been no openness about it. The whole thing has been dominated by the desire to cut costs and to enforce the internal market and the purchaser-provider split, without giving a fig for the people of London and their concerns.

In my brief contribution, I want to refer to the work of a group of London Labour Members which should have been done by the Secretary of State. We undertook an inquiry. We took evidence over 10 and a half hours from a number of people. Obviously, we could have taken a lot more evidence and the inquiry could have gone on much longer, but we felt that it was reasonable to take that amount of evidence, backed up by a great deal of written evidence. Many people gave their time, their information and their energy to tell us what was going on in the NHS in London. I shall quote briefly from Professor Peter Barnes of the National Heart and Lung Institute, who said :

"This Government has destroyed the good will of health workers". The inquiry report says :

"There is clearly a failure in the NHS to consult those who work and use the system in London . . .

Many of the submissions received contained pleas for medical ethics to take precedence over the market ethos."

How often has one talked to nurses, doctors and others who have asked why they have to spend all their time filling in forms about the purchase and the cost of particular medicines ? What is it like for doctors to say that they no can longer prescribe Calpol because it has been taken off the list ? Those are problems at one level, but we may move to a more serious level due to the obsession with cutting costs and with enforcing an internal market in the health service. Our inquiry also demonstrated the many problems that exist in London and the relationship between poverty and ill health. Many, such as Rowntree and Charles Booth, have done work on that subject and have shown that the greatest cause of ill health in this capital city is poverty--poverty through an inadequate public health system, inadequate drainage and inadequate medical services and other such facilities. The slum clearance programmes and the drainage programmes were part of the growth in health provision.

What do we have now in London ? There are 750,000 people who rely on wages that are well below the poverty level, and the costs of living in London are considerably higher than in the rest of country. One in four of all London children rely on free school meals, often as their main source of nourishment. The only reason why they are eligible for free school meals is that their parents' incomes are on the level of income support or below. That is a serious problem. In many schools in my constituency--I am sure that my hon. Friends who represent other inner London constituencies find the same--80 or 90 per cent. of the children who have school meals get them free because of the poverty of their parents.

Mrs. Bridget Prentice : Will my hon. Friend also comment on the relationship between poverty and health and the figures that I have received from the Department of Health about the number of notified cases of tuberculosis in England and in London ? There were 855 cases in 1992 in England as a whole, 258 of which were in London--almost a third in London alone.

Mr. Corbyn : My hon. Friend underlines an important point. If my memory serves me correctly, she has just said that almost a quarter of the cases of tuberculosis occur in

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London ; and London does not have a quarter of the nation's population. Many of the poverty-related illnesses, which were the bane of Londoners in the 19th century and in the early part of the 20th century, are returning. The poverty-related chronic illnesses, which were written about so well by many of our forerunners in the House, are on their way back.

Mr. Ian McCartney (Makerfield) : May I refer my hon. Friend to the recent report of Crisis at Christmas, which shows epidemic levels of tuberculosis among London's homeless ?

Mr. Corbyn : My hon. Friend is correct. It is hardly surprising that people who are homeless end up with tuberculosis. If homeless people are forced to sleep in bus shelters, tube stations or on the streets of London outside expensive hotels and empty, privately owned flats, it is hardly surprising that they contract chronic illnesses. Indeed, our inquiry received evidence from one of the homeless groups that the life expectancy of a man who is homeless on the streets of London is 46. That is an appalling figure and an indictment of our society. We need a health service and an attitude that deal with those problems.

The standardised mortality rates in London, on the analysis of the King's Fund, show that 30 per cent. more residents of inner London areas in the 15 to 64 age group die annually than would be predicted on the basis of national figures. That confirms the point made by hon. Friend the Member for Lewisham, East (Mrs. Prentice) about tuberculosis. We have a serious problem.

On top of that, what do we get but a continual decrease in the number of available hospital beds and the great difficulty that many of those people who are suffering extreme poverty face in getting a GP in the first place ? We gathered evidence from those who deal with such matters. They said that it was very hard for many homeless people to become registered with a GP. Obviously, they have to go to a casualty unit instead to try to obtain treatment.

I recognise that, as the Secretary of State mentioned, the unit that has been opened in the Camden and Islington area is a step forward. However, it would be an even better step forward if GPs were put under some pressure, which ensured that they took on refugees, people whose first language is not English and people who are homeless, because there is evidence that some GPs are reluctant to take on people who fall into those categories.

I am not tarring all GPs with the same brush. Many GPs do an absolutely first-rate, excellent job and are generally concerned about the health of the entire population. However, something must be done about the problems that were illustrated by our inquiry. The Department of Health reported that between 8 and 14 per cent. of patients who were seen by London accident and emergency units were not registered with a GP. Clearly, there is a larger number of people than that who are not registered with a GP.

The Government are talking about transferring resources from hospitals to primary care. We have seen plenty of closures of hospitals and hospitals services, but we have not seen a commensurate increase or improvement in expenditure or in the service provided in a large number of facilities in the primary care sector.

I hope that the Government will be prepared to recognise that there are links between poverty and ill health. There are links between the environment and ill

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health. Why is it that in many schools in London a quarter of all children are suffering from asthma of some sort, as my hon. Friend the Member for Woolwich (Mr. Austin-Walker) pointed out ? If one goes into a school secretary's office, one sees a whole shelf full of nebulisers for children who suffer from chronic conditions of asthma, which is related, in part, to the growth of road traffic and of air pollution as a result. What utter madness to spend so much money on motorways, when we could be improving public transport and reducing pollution. We must consider those problems.

What also came out in our inquiry was the concern of many people for the future of not only special hospitals, but of research institutions in London. Sir Colin Dollery from London university gave interesting evidence in which he expressed deep concern about the future quality of medical research that can be undertaken in London because of the way in which the internal market runs and because of the lack of funding of those resources. I suspect that he was one of many who share that view.

We must also consider the problems of individual hospital closures and the campaigns that surround them. The list of some 16 hospitals in inner and outer London which are all under some threat includes Guy's, Dulwich, Hither Green, St. Bartholomew's and the Queen Elizabeth hospital in Hackney.

I was at a public meeting on Tuesday evening which concerned the future of Bart's. It was a local meeting, near to the hospital in the borough that I represent with my hon. Friend the Member for Islington, South and Finsbury (Mr. Smith). It was packed. The people there were devastated that the courts had ruled against the application made jointly by the London boroughs of Islington and Hackney to keep the hospital open. However, they were absolutely determined to fight for their hospital. That hospital has been there for 900 years. If one talks to anyone outside London

Mr. Spearing : Or in the world.

Mr. Corbyn : Indeed, if one talked to anyone, anywhere in the world about closing an institution of the excellence and with the record of Bart's, they would think we were completely mad. I suspect that we shall be left with a closed hospital and an empty office block on its site.

As for the idea that people should go elsewhere for health care, I refer to the words of the Secretary of State. She said that it is important for the services to go where the people are. Where will the people who live around Bart's, who use Bart's and who come from elsewhere to use Bart's go ? How will they get there ? That will create serious problems.

Serious problems are also caused by the closure of casualty units and the difficulties for ambulances in travelling through London during the rush hour at crisis times. It is not good enough to say that the air ambulance can sort out that problem. There is one air ambulance and that cannot sort out the problem. It will be solved only by maintaining the existing casualty units, which have provided such a good service in London for so long.

There are many other issues relating to the health service and I hope that they will be mentioned by other hon. Members during the debate. London has the principles of a very good health service. There is enormous

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public support for the principle of a national health service free at the point of use. Even the years of Tory Government have not managed to destroy the principle of a free national health service, despite the Government's considerable efforts to try to do so. What we do not have in London is any sense of democracy in the planning or running of our health services ; we have a secretive inquiry by one person who proposes wholesale cuts and closures ; placepeople running the regional and the district health authorities ; and the mania for the internal market dominating everything that goes on in every hospital and health service institution throughout London.

What we need is some democracy in the running of the health service. We need a London health authority that can plan for the needs of the capital city and preserve the centres of excellence that have given such good service, not just to the rest of this country but to the rest of the world. Instead, we are getting a domination of the service--domination by the internal market, domination by the worst aspects of accountancy, and a consequent loss of so many people's morale and faith in the health service.

The debate is very important and timely. Those who are trying to destroy London's health service--and I believe that some are--will rue the day that they did such things. It is important that we understand that the people of London are suffering from unemployment, poverty, ill health and a lack of certainty of the availability of an ambulance or hospital bed when they so desperately need it. Nothing that has been said by Secretary of State or the Tomlinson inquiry does anything to take away those concerns and fears.

We are suggesting today a London health authority. London is not over- provided for or over-bedded ; if anything, there is under-provision. We want a recognition that if we are to have a healthy capital city, we must be prepared to spend the necessary money to pay for it. Closing hospitals is hardly the way to start doing that.

7.21 pm

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