House of Commons Hansard Debates for 28 Apr 1994

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being over-funded. The reply is to be found at column 72 of Hansard of 12 April. But the paper did not look at the answer in sufficient detail. It should have looked at note 2, which clearly states that that excluded spending on London's postgraduate special health authorities, which consume an enormous amount of money. I was concerned about the information, and my hon. Friend the Member for Worcester (Mr. Luff) and I tabled further questions to the Secretary of State for Health. We wanted to be clear about the real funding, and it was shown that another £50 a head should be added to the London figures.

Perhaps even more significant was the fact that earlier tables did not show the split between inner and outer London. That is crucial and those figures, which are contained in Hansard of 21 April, clearly show that inner London funding is 56 per cent. higher than the national average. Who could argue that that can be justified ? I cannot say exactly what the figure should be, but 56 per cent. seems excessive, particularly when the figure for outer London is only 8 per cent. above the national average. That is important in terms of resources and, as mine is an outer-London constituency, I am especially interested in those percentages.

In making a judgment about resources, we also need to look at the needs of London. We know that much money is tied up in the teaching hospitals and that costs are higher in London. Like other hon. Members, I should like to draw attention to the social deprivation in parts of London.

The important Tomlinson report suggested that the number of beds in London could be reduced over a five to 10-year period by between 2, 000 and 2,500 and that, at the same time, resources could be shifted to primary care. That process was started by the Secretary of State who rightly made £85 million available this year for investment in primary care in London.

Beds are a crucial part of the equation. I am loth to open the issue of beds because I know that Opposition Members are obsessed with it and that beds are not the best indicator. However, the record needs to be put straight, because there is much misunderstanding. Over the past 10 years, we have succeeded in significantly reducing the number of beds in the national health service while managing to treat many more patients. Therefore, beds are not the crucial factor.

Tomlinson drew heavily on the King's Fund report entitled "London Health Care in the Year 2010" which was published in 1992. Page 47 of the report details the number of beds per 10,000 residents and clearly shows that London is over-bedded compared with England. It also showed that, compared with similar cities, London was not as over-bedded as people believed. That seemed to be a great revelation to the Evening Standard and Opposition Members.

London has 43.6 beds in inner deprived areas per 10,000 of population compared with 41.6 beds in comparable British cities. That shows that there are problems in some of those other cities that will need to be addressed. Crucially, London's 43.6 beds compare with 25.4 nationally and that cannot be ignored.

Mr. Tracey : My hon. Friend has mentioned the commentary on London's hospitals by the Evening Standard . We all respect that newspaper, but does my hon. Friend agree that it should have done its homework a little better ? I have a slight worry, which no doubt is shared by

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other hon. Members, that perhaps some of the Evening Standard comments on this critical matter have been rather misleading to Londoners.

Mr. Congdon : One of the problems is that many people have tried to rubbish the Tomlinson report by saying that they have found new information. There is no new information : it is all in the excellent report by the King's Fund. That was why I was somewhat surprised by the document which I received yesterday called, "London, the Key Facts" which is not as well produced. It is a much briefer document, but even that document says that inner London has 50 per cent. more beds per capita of resident population than England as a whole. Therefore, there should not be a problem over the issue of beds, but some people do not seem to understand the situation. The King's Fund suggested that London could see a reduction of about 5,000 beds. The Government have not proposed that. They have proposed the lower end of the range and that is right and proper.

Hon. Members might ask how those figures are derived. They are derived from all sorts of things such as patient flows and improvements in day surgery. We know that more people can be treated on a day basis, so that fewer people need to be treated for longer in hospital. In addition, the length of stay in London teaching hospitals is 15 per cent. higher than in provincial teaching hospitals. Even more crucial and revealing is that if inner London hospitals could achieve the level of performance of hospitals elsewhere in the country, London could make do with 2,740 fewer beds. That is not my figure ; it is the figure from the King's Fund report.

Therefore, I conclude that London can make do with fewer beds. But it is important to ensure that that is only done in line with improvements in primary care and by monitoring carefully the pressures on health services in London.

Another crucial aspect of health services in London is the funding formula. It is difficult to devise a sensible formula for funding. There have been various formulae over the years. My area does not seem to benefit from any funding formula, so I would welcome something different.

It is difficult to achieve some of the changes in London while resources are being moved away from London, particularly in the various Thames regions. That needs to be looked at carefully. It is not clear exactly what is happening in each district health authority in London in terms of funding. The situation is confused by fundholders using money to purchase services. But we should be cautious about moving funding away from London at the same time as we are trying to implement the much-needed reforms.

The funding formula has to be considered in order properly to take into account social deprivation. I welcome the fact that "The Health of the Nation" sets targets. I believe that they will clearly show the differences in quality of health in different parts of the country, and that information should be used to drive the funding of individual health authorities.

There is no doubt, when one talks to health authority representatives, as the Select Committee on Health has done, that health authorities outside London do not face the same problems as London health authorities, particularly those in inner London, and particularly, as has been mentioned, in terms of the mentally ill. There is no doubt that more needs to be spent and has to be spent in inner city

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areas than in some rural areas on the mentally ill and their needs. I hope that when my right hon. Friend the Minister for Health replies he will consider formula funding in terms of London.

The health reforms have achieved a great deal. The internal market is leading to services being provided more closely according to need, which, in turn, is leading to benefits in outer London as well as in areas further away from London.

I am also convinced that the other reforms concerning fund holders are leading to massive and valuable change in the health service. I urge hon. Members to read the minutes of the Select Committee's meeting last night with fundholders when they are published. They show where the dynamic in the system is leading to real improvements in primary care, improvements in the services provided in doctors' surgeries and improvements in services provided across district health authorities, not leading to the sort of two -tier service that Opposition Members allege exists, but improving the service to all patients.

I congratulate the Government on those reforms and I also support the desire to ensure that we implement the proposals in the Tomlinson report sensibly. My only concern is that we ensure that we implement them at a pace commensurate with the improvement in primary care, to ensure that the services can take the strain of that change, because any change is difficult.

It is not an option in my view, as Opposition Members, especially the Liberal Democrats, say, to hold fire and not to do anything at the moment. The issue has been fudged for far too long. That is why residents of inner London do not get as good a deal in health services as they deserve. We need to get on with it and I congratulate the Government on their courage in doing so.

9.15 pm

Mr. Nigel Spearing (Newham, South) : There is one thing that the hon. Member for Croydon, North-East (Mr. Congdon) said on which there is agreement across the House : there is some need for change in the health service in London. What we disagree about is what that change should be and the fundamental levels on which it should be founded. I shall return to that major division at the end of my speech. I wish to devote most of what I have to say in about five minutes to the ambulance service. The performance of that service is clearly visible. The patients charter says that, within eight minutes, 50 per cent. of calls should be answered and within 14 minutes, the figure should be 95 per cent. Everybody in London knows that that is not true of London.

I presented a petition to the House on that subject as long ago as 7 December 1990. Even before the dispute about that answering time, the figures began to drop. For many years before 1988, 90 per cent. of calls were answered in 14 minutes, and ever since then the figure has dived to 63 per cent. and has not changed in the past two years. That has occurred because the funds were not demand-led by patients in the street or by emergencies at home.

A written answer from the Under-Secretary of State for Health said that the managers

"must provide services within the resources allocated".--[ Official Report , 3 March 1993 ; Vol. 220, c. 172. ]

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In other words, it was top-sliced on an abstract figure. Of course, those providers are not as accountable as they used to be under local government.

The Secretary of State, who I am sorry to say is not here, made a very long, three-times-round-the-course, speech. I pressed the Chair during her speech, for which I offer a partial apology, but, if I may so, the right hon. Lady was not even competent enough to tell hon. Members whether she was giving way. If she were able to tell hon. Members, I would sit down. I had to intervene, because there was no sign from her.

Several months before the breakdown of the London ambulance service, I warned the Secretary of State to consider it. I warned her in an official letter delivered in an unconventional way. I did that because I did not have any faith that the private office would let her see it. The right hon. Lady made partial reference to that letter in her speech.

The improvements did not come, so, as she said, £14 million is now allocated to the London ambulance service with the objective, according to a reply on 11 January, of putting 15 per cent. more vehicles on the road. Is 15 per cent. enough ? The Government may not achieve their calculated increase, but even if they did, is it enough ? The difference between 63 per cent.

Lady Olga Maitland rose

Mr. Spearing : I am sorry, but I cannot give way. The hon. Lady knows very well that she is not very happy in Parliament. I shall not give way to her, for reasons that she knows very well, quite apart from the lack of time.

There is a limit of 95 per cent. and 63 per cent-- [Hon. Members :-- "Why not give way ?"] I am not going to waste time explaining. At the moment, 63 per cent. of calls are answered in 14 minutes, and that rate needs to increase by 50 per cent. How can 15 per cent. more vehicles on the road provide an increase of 50 per cent ? Other factors might help, but it will not bridge that gap. I regret to say that that £14 million is probably not enough. The basis of our problems in the health service is that the Government have chosen the wrong method of rationalisation, or providing what they call "value for money".

We have competition among the hospitals of east London. Newham general hospital is now a trust and could go bankrupt. It is in competition with other hospitals in London. It has to keep afloat by competition. Is that how one keeps a hospital afloat ? GPs in east London are now accountable to, or are run by, a new-fangled organisation called the City and East London family and community health services, or CELFACHS--not a happy acronym. It is now a trust. Is it right that it is not accountable to local people, as the old family practitioner committees were ? At least they were under some local authority elected and accountable management.

Are competition, profit-making, surpluses and statistics, about which we heard much from the hon. Member for Croydon, North-East (Mr. Congdon), the right way to run a health service ? No, because it is competition.

I close on the note on which I started and I tell the hon. Gentleman and all Conservative Members why : fundamentally, it is not, as I have challenged hon. Members who represent London constituencies to argue, based on the Christian principles on which both the health service and a

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good deal of public life was originally based. Why ? Because it makes a commodity of the difference between a body needing medical attention and advice and one that does not. Can we reduce that difference to a commodity ? No, we cannot and should not, because if we do, we deny the humanity of us all.

Mr. Tracey : On a point of order, Madam Deputy Speaker. I trust that, as a courtesy to the House, the hon. Member for Bristol, South (Ms Primarolo) might like to explain the whereabouts of the hon. Member for Sheffield, Brightside (Mr. Blunkett), the Opposition spokesman on health. I think that the Labour party has rather demeaned

Madam Deputy Speaker (Dame Janet Fookes) : Order. That is not a matter for the Chair, as the hon. Gentleman well knows.

9.21 pm

Ms Dawn Primarolo (Bristol, South) : The debate has ranged over a large area and involved the rewriting of history, and the reinterpretation of many reports to support the Government's policy as it currently exists. I should remind the House that, originally, the reforms were introduced by the then Prime Minister, now Baroness Thatcher, to reduce health expenditure. When they were introduced, the then Secretary of State for Health said :

"Next year . . . we propose to reform the NHS : the coming winter will end the last year of an entirely unreformed service. The winter of next year will not be dominated by cancelled operations, closed wards and cuts in services".--[ Official Report , 11 January 1990 ; Vol. 164, c. 1124.]

He should have added, because it would dominate every day, every week, every month in every year of the reforms.

In that period, we have seen massive bed closures, problems in our health service, not only in London but in Birmingham, Manchester, Bristol and across this country. The Government claimed that the health service in London needed to be reformed because it was overfunded. Indeed, we have heard that repeated today. London got more, it was said, than its fair share of resources. Change was inevitable not because the health service needed to change ; it was inevitable because it was to be cash-driven by a reformed service and a desire to transfer resources out of London.

The figure trotted out regularly was that London had 20 per cent. of the resources and only 15 per cent. of the population and therefore cuts must follow. I recommend to hon. Members that the best way to measure the expenditure in London is to go to the regional health authorities and ask them for the allocations in budget for each of the district health authorities that make up the four regions that converge in London for 1994- 95. What they will find is that London's allocation of the national cake is 15.4 per cent. of the total budget. According to the figures, London is funded 15 per cent., not 20 per cent.

In contributing to the debate, my hon. Friends the Members for Woolwich (Mr. Austin-Walker), for Islington, North (Mr. Corbyn), for Newham, South (Mr. Spearing), for Lewisham, West (Mr. Dowd), for Lewisham, East (Mrs. Prentice) and for Hampstead and Highgate (Ms Jackson) have catalogued the feelings of their constituents, their experiences of health care in London and their disbelief at the Government's presentation of their reality.

They cannot understand why London is supposedly over-bedded, yet they cannot get hospital beds. If London is over-bedded, they cannot understand why their hospitals

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are going bankrupt. They cannot understand why, when the Government claim to be investing in primary care, their services continue to decline, not improve. They cannot understand why, despite what the Government say, their ambulance service is not reaching the national targets for arriving when called out on a 999 call.

There has been much discussion about the King's Fund. When we look at the reports, whether they be the Tomlinson report, the first King's Fund report, the second King's Fund report, or the second of the two reports produced in the past week, we must look at the context in which they were drafted.

Tomlinson was told to take as given a reduction in expenditure--that is, because London is overfunded--to take as given that London is over-bedded and to take as given an internal market that will further reduce expenditure in London and then to produce a plan for London's services. The Tomlinson report specifically excluded a health needs assessment on the population of London--Tomlinson was specifically required to exclude that.

The new evidence today from the King's Fund suggests that London is underfunded to the tune of £200 million in 1993-94. If the Government hold the King's Fund in such high regard, as they claimed today, what they should do is not pick and choose among the King's Fund reports they agree with, but look in detail at the evidence that is being produced.

Newly emerging evidence suggests that the presently weighted capitation targets underestimate the needs of London. London is Europe's largest city. Seven million people live in Greater London, and a further 4.3 million people across the south-east of England depend on its services. Inner London has lost acute beds faster than elsewhere, and its residents in many parts are being told that they simply will not have proper cover.

Take the 1 million residents in north-east London who will not receive cover from the national health service for anything except the following four categories : emergency admissions ; urgent hospital admissions ; people waiting more than 18 months ; and obstetrics cases. Those will be the only national health services offered to 1 million Londoners in the north-east of the city. It is simply not good enough.

Lady Olga Maitland rose

Ms Primarolo : With respect, it has been a long debate, and both the Minister and I want to make our case. I will not give way at this stage to the hon. Lady.

The needs of London are becoming greater. The incidence of premature mortality is much higher in inner London than in the rest of the country, as is that of neonatal mortality. Inner London has four times the national proportion of people from ethnic minority groups, who have special health needs that we should respect and provide for. Inner London has higher unemployment rates, and London as a whole has a much higher incidence of overcrowding and households that lack basic amenities.

There have been massive hospital closures in London. One in five accident and emergency units have closed, with no replacements. Now the Government are turning on the hospitals. For example, the Queen Elizabeth hospital for children in Hackney is to be closed. It is in the most deprived area in the country, covering Hackney, Newham and Tower Hamlets.

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Its 107 beds are to be halved and will be split between two nearby hospitals, destroying one of only two hospitals for children in London, all because of a supposed shortfall of £20 million which is needed to upgrade the building. Incidentally, it is worth noting that charitable income for the other branch of the Queen Elizabeth hospital--Great Ormond Street--is more than £20 million and could cover the shortfall.

Overseas private work generated at Great Ormond Street could do a great deal to support the other hospital, but no, the Government intend to do worse. By the end of this century--within six years--they intend to halve the number of paediatric beds in the city. Much has been said about general practitioners' premises in inner London. In 1982, 15 per cent. of GP premises were below national standards, but by 1992 the Tomlinson report found that the situation had deteriorated further, and that 46 per cent. of GPs' surgeries were substandard. That is during this Government's stewardship. What about investment in primary care ? What is the result of all the money that the Government have been putting in ? There are 2 per cent. fewer GPs, 5 per cent. fewer health visitors, 11 per cent. fewer district nurses, but there are 32 per cent. more managers. That shows the Government's priority and the system that they want to operate.

Let no one say--not even the Minister--that we do not have a two-tier health service. I shall give him an example--a phone call today-- [Interruption.] This is not funny. A one-stop breast cancer clinic at Charing Cross hospital was telephoned today about a referral. The hospital wanted to know whether the patient was from a fundholding GP and therefore whether she would be given priority. The answer was, "I believe so." I suppose that the Minister would deny that that happened, and that that person could not get any treatment in the clinic at this time.

On 25 April, in an exercise called "Casualty Watch", 58 Londoners were found facing long delays in the casualty departments of 13 leading hospitals. There were not enough beds to put the people from casualty in.

Let us know the truth about London's vanishing beds. In 1982, London's health districts had 26,297 acute hospital beds, but by 1990 the number had dropped by almost 7,000. Now London has 17,181 acute beds.

The numbers on waiting lists are soaring. Londoners are waiting longer and in greater numbers. There is less care for the elderly because some hospitals have gone and others are threatened with closure.

Londoners are being told that their hospitals have too much money, when the reverse is true. London's ambulance service is not responding to Londoners' needs.

But not only inner London hospitals are suffering. In Kingston, which was mentioned earlier, 22 beds have been closed by what we have been told is a flagship trust, because it has not enough money. As I have said, in nine months waiting lists in Redbridge have risen by more than 100 per cent ; yet the Government constantly tell us that everything is all right.

A patient from Acton who was referred to the Eastman dental hospital was refused an appointment on the following basis : "I regret that we are unable to offer a consultation appointment as requested.

We are now receiving more of this type of referral than we have resources to see and under our current funding arrangements the

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only effect of accepting them all would be to run up ever increasing waiting lists. This would be frustrating for everyone concerned"

particularly the Government

"and goes against the thrust of the Patient's Charter, established by the Government."

To ensure compliance with the patients charter, people are being denied appointments in the first place.

Throughout the time in which the number of beds has been falling, the money available has been falling as well. What has been happening in the private sector in London ? If beds are not needed, there should be no increase in the private sector, either ; but between 1979 and 1983, there was a 41 per cent. increase in the number of private beds.

The Government tell us that beds are not needed. Why are people prepared to pay for them privately, when they are denied them in the national health service ? Because they need them, that is why. During the same period, the astronomical salaries of bureaucrats rose by 110 per cent.--money for patient care that could have been spent elsewhere.

What do Londoners say about all this ? What has the King's Fund established ? It seems to be trendy to ask Londoners what they think after the health service has been destroyed rather than before, because the Government do not consult ; but what do patients say ? They say this :

"The National Health Service should continue to provide comprehensive healthcare for all Londoners as a right with access irrespective of the individual's financial resources or economic status."

We want to see more money, not less, going into quality care in London.

"Whilst recognising a limited . . . role for private health care, NHS resources of equipment, trained personnel and in-patient facilities should be for the exclusive use of the public health sector"

national health service patients, not the private sector. There should be well-resourced hospitals :

"Primary care . . . should be resourced to offer an expanded range of services".

Discrimination should be eradicated. Complementary therapies should be brought into the national health service. Health promotion and education need to be on a wider basis, recognising that poverty, poor housing and inadequate access to community-based services are crucially linked to people's health.

The Government have completely ignored those criteria when aiming for the targets identified in "The Health of the Nation". They have consistently said that we oppose change, but that is not true ; what we oppose is change for the sake of change, or change that is driven by market forces, commercialisation and privatisation. We believe that change should be based on the health needs of Londoners, not on a market philosophy.

The Government have got it wrong. They are presiding over chaos in London, and Londoners know it, even if the Government do not. What we want, and what Londoners want, is a regional health authority for London, planning for London ; a moratorium on closures ; a planning structure that meets those needs ; and management of change not through the vagaries of the market but planned to meet the needs of the population of London. I urge my hon. Friends to vote for the motion.

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9.39 pm

The Minister for Health (Dr. Brian Mawhinney) : The hon. Member for Bristol, South (Ms Primarolo) finished her speech by saying that the Labour party was not against change. I must say at the end of what has been a long, and occasionally acrimonious, debate that there is not a shred of evidence to substantiate that claim.

The hon. Lady and her hon. Friends said all afternoon that they were against this change, that change and the other change. Not once--not from the hon. Member for Holborn and St. Pancras (Mr. Dobson), to whom I shall return later, the hon. Lady or any of her hon. Friends--did we hear from Labour Members what changes they were in favour of.

We know that the hon. Lady wants a moratorium ; in other words, she wants to add to the uncertainty and confusion of London's health care. We know that she wants a regional tier and planned health care. That came within 30 seconds of her being rude about the increased number of planners, managers, administrators, bureaucrats and all the other hard-working members of the national health service around whom she laid her tongue this evening.

The truth is that the Labour party is against change. However, nearly everyone who has looked at London's health service agrees with Sir Bernard Tomlinson's general conclusion that some rationalisation and reorganisation should occur. That was the Labour party's position as enunciated by its spokesman in the other place. My hon. Friend the Member for Hertsmere (Mr. Clappison) drew attention to that in what I thought was an excellent speech.

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

That was said by Professor Bosanquet, professor of health policy at St. Mary's medical school and Imperial college.

"The balance of health and social care in the capital is not appropriate to the needs of Londoners. However, adjusting the balance will inevitably take time. The Secretary of State has shown great courage in making people face up to the need for change. Now the task is to work through these changes on the ground, building up good alternatives that are affordable, that work, and that make a better framework for the long term."

That was said by the chief executive of the King's Fund. When the Labour party says that it is not in favour of change, it finds itself isolated not just from the Government--its normal expectation--but from its own Front Bench in the other place and from experts whose disinterested observation and input in the health scene in London is beyond the contradiction of anyone--except someone like the hon. Member for Holborn and St. Pancras.

Mr. Dobson : Will the Minister give way ?

Dr. Mawhinney : I will, but later. The hon. Gentleman may wish to intervene later.

I am glad that the hon. Member for Southwark and Bermondsey (Mr. Hughes) took part in the debate. His colleague who normally speaks on health matters--the hon. Member for Rochdale (Ms Lynne) keeps telling us airily- fairily that his party would spend more money on health. I was grateful that the hon. Member for Southwark and Bermondsey identified 5p in the pound as a reasonable increase in taxation, which he thinks should be devoted to improving health care. Mr. Simon Hughes indicated dissent .

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Dr. Mawhinney : If the hon. Gentleman shakes his head in amazement, I invite him to look at the Hansard record of his speech. That is 5p in the pound for health, and at least 1p in the pound for education. It was worth having the debate so that people in the south, the south-west, London and the rest of the country who might be tempted to listen to the siren multiple voices of the Liberal Democrats next week will understand that, when the party puts forward a health policy, it carries a tag of 5p in the pound extra in taxation.

The real problem about the hon. Gentleman's speech was that he ducked the point which, I hope that he agrees, I put carefully, gently and thoughtfully. I asked the hon. Gentleman what should happen in the face of the evidence that £18 million and rising is going into the Guy's and St. Thomas's trust and the clinical incoherence testified by the clinicians on both sites, and he ducked the question.

Mr. Simon Hughes : I can deal with both points. First, the record will show that the 5p in the pound related not to party policy but to opinion poll evidence of what a significant proportion of the electorate is willing to spend. Some 83 per cent. of the electorate believe that more money should be spent on the health service. Secondly, on Guy's and investment, the Minister knows perfectly well that £18 million compares with the £150 million being spent on Sir Philip Harris house. He knows that the view in both hospitals is that the services provided will not fit on one site and that a rational disposition of services across two sites is possible if only the Minister would listen to advice.

Dr. Mawhinney : That is not what the clinicians said to me. I speak with some authority because I was the person to whom they spoke. When I spoke to the clinicians and the trust, they told me that it was possible to put all the acute services on the St. Thomas's site. I have seen with my own eyes how that can be done. On the hon. Gentleman's first point, he rolled his tongue so lovingly around that 5p in the pound extra taxation that no one who heard him doubted the message that he was trying to convey to the public.

I agreed with my hon. Friend the Member for Croydon, North-East (Mr. Congdon) when he asked, in another excellent speech, why Labour Members never mentioned the good things that happen in the health service. It was no coincidence that he spoke on the back of what we have now come to accept as the traditional whine by the hon. Member for Hampstead and Highgate (Ms Jackson). She quoted from four constituents' letters. That leaves 40,570 in -patients and day-case patients and 194,883 out-patients at the Royal Free, none of whom she discussed because she, I, the Royal Free, the House, London and the country know that the hon. Lady likes to try to make the abnormal and the singular appear normal.

As the hon. Lady represents one of the most successful trusts in London, I should have been more impressed if she had felt able to give it some credit for the 7.6 per cent. increase in in-patient and day cases and 9.3 per cent. increase in out-patient cases which that hospital managed to achieve last year.

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