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House of Commons

Friday 21 October 1994

The House met at half-past Nine o'clock


[ Madam Speaker-- in the Chair ]

National Health Service (London)

9.34 am

Mr. Harry Cohen (Leyton): I beg to move,

That this House expresses its anxiety at the current state, and future prospects, of the National Health Service in London; considers that claims made by Health Ministers that there are too many hospital beds in the capital and an over-allocation of health resources, are not proven; notes that many of London's health authorities and trusts face chronic levels of debt due to Government underfunding of the National Health Service, and this along with the internal market' is having a devastating impact on London's health service; notes that accident and emergency units work under increasing crisis conditions; notes that the London Ambulance Service has been reduced to the worst ambulance service in the country; notes that general practitioners in many parts of London receive less than the national average to treat their patients and that they face an increasing workload due to the impact of hospital closures; considers that Outer London's health service is also suffering from the Government's health policies resulting in large debts, large waiting lists and repeated cuts in treatment provision; notes that there are 100,000 on waiting lists for treatment in the capital but that the number of people affected is much higher; and so calls upon the Government to heed the voice of the vast majority of Londoners, and to introduce an immediate moratorium on further bed reductions and hospital closures in the capital, whilst work is urgently undertaken to shift the system toward the health care Londoners need.

I am pleased to have won this debate. I have chosen the subject of the national health service in London because it is of great importance to most Londoners. There is considerable concern over its current state and its prospects, if being run down can be called a prospect. For many people, it is a life-and-death issue.

First, I pay tribute to nurses, doctors and other health workers who provide magnificent care, increasingly against the odds and against current trends. I pay tribute to those doctors, nurses and health workers in my local hospital, Whipps Cross, especially those in ward B3, who, for the past four weeks, have been providing excellent care for my mother.

As I said, health workers, in their important caring role, are having to endure increasingly arduous, testing and demoralising conditions. Many of them are exploited and underpaid. Many of the auxiliary nurses and care assistants, for example, work very long hours--13-hour days are not uncommon. One nurse told me that her job description was to assist, but, actually, she and the other nurses ended up doing the full nursing job.

In many ways, it is a cheap labour force in our hospitals, yet the Government are resisting the nurses' pay claim. Ministers have said that they will not allow any claims beyond 2 per cent. That is from a Government who themselves have been tainted with greed and sleaze, and who have allowed the NHS managerial salaries bill to rise by 211 per cent. in the three years between 1989-1990 and 1992-93, while £95 million was spent on redundancy

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payments for, among others, nurses. Nurses do a tremendous job under increasing pressures, and they should get a pay rise that reflects their productivity and worth.

I could fill a speech such as this about the health service with many examples of individual cases, but I shall cite only a few current cases from my mailbag. There was the case of a man who was discharged from hospital far too early--in this instance, following a vasectomy. He awoke at 11.30 am and was discharged at 12.40. On being discharged, he collapsed and bled internally. His genitals turned black and distended and he was unable to return to work for weeks. There was the case of one of my constituents who had a tonsillectomy after waiting for two years. He then got a wound infection and a re-growth of the disease tissue and had to begin the whole process of waiting again--three months' wait just to get an out-patient appointment, and he still has a long wait for a second operation. He tells me that he has been suffering pain and side effects for three and a half years.

Then there is the case of the young man with a lump and pain in his groin, who was told that it would take two years to receive an operation on the national health service. He struggled and took out a £1,800 loan for a private operation. It was a good job he did so, because a ruptured hernia was discovered. There was the case of the man in the accident and emergency unit with severe chest pains, who spent eight hours on a trolley waiting for a bed. A pensioner whom I saw last month at Leytonstone station told me that her appointment to see a consultant was for August 1995. All that time, of course, she is not counted as being on the official waiting list.

As I said, citing such cases could take up the entire debate, but I want to move on to the issues and the arguments. It is worth remembering, however, that many thousands of individuals are behind those issues and arguments, and that they are affected by the cuts in our health service.

First, I want to concentrate on the proof that London is not over-bedded. Reports have claimed that London is over-bedded, and Health Ministers have leaned on that claim very heavily for the implementation of their policies. I believe that some, like the Tomlinson report, were set up by the Government deliberately to reach that conclusion.

Tomlinson estimated that between 2,000 and 7,000 beds could become "surplus" before the end of the decade. The Government's document "Making London Better", which was published in February 1993, refers to a rationalisation of acute hospital services involving a reduction in requirement for hospital beds of 15 to 20 per cent.--2,000 to 2,500 beds-- over the next four or five years.

Thousands of bed cuts have already taken place, and many more are in the pipeline as a result of the assumption that London is over-bedded. London lost 28 per cent. of its hospital beds between 1986 and 1991. The assumption has been increasingly challenged and discredited. It is challenged on anecdotal evidence that people face long delays before a bed becomes available and that patients have to wait on trolleys. That may be anecdotal, but it is real for many people. Perhaps the

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Government can explain that contradiction. If that is not caused by a shortage of beds, presumably the cause is the system of management.

Waiting lists continue to rise. That does not imply surplus beds. Perhaps the Government can explain that contradiction. We must also consider cancelled operations. North East Thames regional health authority recently said:

"Between April and June"

of this year,

"hospitals across the region recorded 2,408 patients who had their operations were cancelled; 558 of whom were not readmitted within a month."

If there are surplus beds, why are there such levels of cancellations? The Government should explain that.

In its 1992 working paper entitled "Acute Health Services in London", the King's Fund started the more recent academic challenge to the assumption that London is over-bedded. It divided London into three categories: high status, urban and inner deprived. It stated that there were more beds in the deprived sector than the average. However, that was also the case in similar areas such as central Birmingham and Liverpool. That is historic, but the higher than average bed provision matches the pattern of poor health status. Therefore, the higher level of beds corresponds to the higher level of need.

Professor Jarman, a respected academic in the field, has joined the attack on Tomlinson. He said that Tomlinson failed to include geriatric and non- acute beds, and that, when the results are standardised for age, there is only a 0.2 per cent. difference. Professor Jarman continued:

"Hospital use in London is comparable to national norms, contrary to the claim that Londoners use more hospital services than they should."

Professor Jarman extrapolates that both acute beds and all beds per resident in London are now at the national average.

Mr. Iain Duncan Smith (Chingford): I congratulate my neighbour, the hon. Member for Leyton (Mr. Cohen), on securing the debate and on being first on the list. That is something I have yet to achieve. However, I want to question the supposed differences in the Tomlinson and Jarman figures, because there has been some dispute about them. It is clear that Tomlinson had a much tighter focus than Jarman. He considered acute beds specifically, and that led to the original report. However, Jarman widened the issue to all beds in London. There has never been an argument that there are not enough beds in London in all areas. However, the question is, are there too many acute beds and not enough in other areas of necessary treatment? That is where the argument lies.

Mr. Cohen: I believe that Tomlinson has been increasingly discredited. The Government claim that there were too many beds in London overall. That is why the number of beds is being reduced and hospitals are being closed right across London.

Professor Jarman is supported by the King's Fund in its report entitled "London: The Key Facts" which was published in April 1994. The report states that there are the same number of beds in inner London as in other conurbations.

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As well as the centres of excellence which are renowned worldwide, London has special health needs. It has higher than average numbers of elderly and housebound people, HIV and AIDS patients, alcoholics, substance abusers, people with severe mental health problems, homeless people, single homeless and refugees. In addition, there are the tourists and commuters, who do not always show up in the official figures.

Professor Jarman has said:

"Bed closures should take account of London's relatively poorer health and primary care circumstances, longer hospital waiting lists, poorer provision of residential homes and evidence from the Emergency Beds Service of increasing pressure on beds."

In its August report "What's Next for London's Health Care?" the King's Fund called for

"no more acute reductions overall and great care about A&E Departments, while the pressure on both remain as intense as they are now."

Mr. David Congdon (Croydon, North-East): Does the hon. Gentleman agree that it would have been more helpful if the King's Fund had carried out more original research, rather than simply relying on the research of Professor Brian Jarman? The earlier report in 1992 was excellent, and Tomlinson drew on it. Unfortunately, the latest report is nothing more than a rehash of Jarman's discredited work.

Mr. Cohen: The Conservatives were happy to quote the King's Fund when it led them to close hospitals and beds. However, now that the King's Fund is saying that there should be no more acute closures, it is being renounced by the Conservatives. That argument simply will not do.

London has fewer acute beds per head of population than Newcastle, Greater Manchester, Liverpool, Sheffield and Leeds. The United Kingdom has fewer acute beds per head of population than Germany, France, Belgium, the Netherlands, Ireland and Spain. Paris and Rome have 50 per cent. more beds per head of population than London, and Berlin has twice as many. However, the Government are absolutely obsessed by their false assumption that there are too many beds. As a result, 16 hospitals face a serious risk of closure. They include Guy's, Bart's, the Queen Elizabeth in Hackney, Oldchurch and many others.

There are no longer continuing care beds for the elderly in areas such as Bromley. There are just six in Kingston, and virtually no provision in Greenwich, Harrow, Hounslow and many other parts of London. The choice for many of those elderly Londoners is to struggle alone at home or be forced into private nursing homes, some of which are unmonitored and might well be dangerous. What a way to treat the generation which won the war for this country.

It is not just a question of over-bedding. I want now to consider the allocation of health resources.

Mr. Bernard Jenkin (Colchester, North): I note the hon. Gentleman's admiration for the Italian health service in Rome. I hope that he will not take us in that direction. I speak for an Essex constituency. The hon. Gentleman has compared the number of beds per head of population, but Essex also has big social problems, such as a heavy preponderance of elderly people. We are miles behind

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because of the London effect, which displaces resources to the centre away from the surrounding home counties. What is the hon. Gentleman's solution to that?

Mr. Cohen: That is not true. I do not really want to jump ahead of my speech, but I will do so now, to inform the hon. Gentleman that waiting lists in Essex have increased by 30 per cent. under this Government. That gives the lie to the hon. Gentleman's argument. The Government have the false assumption that there are too many beds in London. As I have explained, that simply is not true, and the Government should reverse their attitude in that respect. There is also not an over-allocation of health resources to London. London has 15 per cent. of the English population, but its share of NHS hospital spending is a fraction over 15 per cent. this year. However, within that is the provision for special needs to which I have referred, London weighting and the higher cost of the teaching hospitals. London is not overfunded. The King's Fund Research Institute, which Conservative Members do not like now that it is producing this kind of information, has said:

"instead of losing £17 million, London should gain an extra £200 million."

Mr. James Clappison (Hertsmere): The hon. Gentleman referred to underfunding in London. I would be interested to know whether he is arguing that resources should be transferred from other regions, or for an increase in health service expenditure. If that is the case, would he share my interest in hearing the Opposition Front-Bench spokesman's response to what he has just said?

Mr. Cohen: The hon. Member for Hertsmere (Mr. Clappison) is jumping ahead of my speech. There should be increased resources for the national health service in London and throughout the country. One thing that can be done first is stop the chronic wastage in spending. I have some examples. The King's Fund, in "London: The Key Facts", states:

"newly emerging evidence suggests that these weighted capitation targets underestimate the needs of inner city areas."

The Department of Health itself commissioned a York university report, which it received in April, but, in its jargon, it is still being evaluated. The Government are sitting on that report. It is deliberate procrastination. I understand that the report states that, taking account of social deprivation, money would come to many areas of London. It is a scandal that the Government are sitting on those facts while they push ahead with financial cuts and closures.

Mr. Nigel Spearing (Newham, South): I am sure that my hon. Friend joins me in deploring the Secretary of State's absence, in view of her part in London hospital closures. Does my hon. Friend agree that allocations to health services are important in regard to the new trusts? I am sure that my hon. Friend is aware that, in east London, there are applications for trusts on a borough basis for community health services. There is a very good case for them, and they are being applied for, but the Secretary of State has not yet decided. There must be an

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overriding reason for such trusts as against a three-borough trust, which would tend to be more bureaucratic.

Mr. Cohen: My hon. Friend makes a good point. Borough trusts are wanted in his area of Newham. Of course, the financial squeeze is leading to trusts merging in ever larger conglomerations. Under the weighted capitation formula, it has been estimated that £119 million will be siphoned off from London's annual health spending by the end of the century. Outer London is the worst affected. It will lose £96 million out of £119 million. Many boroughs are big losers under the capitation formula.

The internal market is having an appalling effect. In 1992, the King's Fund forecast that 15 major acute hospitals and postgraduate specialist hospitals would close before the year 2000 because of the internal market. That is an underestimate. There is very little effective planning and no stability for London's health services because those values conflict with the internal market, and the internal market takes precedence every time.

Purchasers and providers, as well as increasing bureaucracy in the NHS, are driven by their own monetary considerations rather than by the treatment that patients need. Nurses and other essential health workers have been squeezed out while managers and accountants have proliferated.

There is precious little co-ordination of overall health services. For example, I have written to the Minister and the regional health authority about children's beds in London. Trusts are announcing closures without concern for implications elsewhere.

In July last year, a well-established right-wing medical figure, Dr. James Le Fanu, wrote an article in The Daily Telegraph referring to

"the anarchy of a free market in health which is based on ideas of what ought to work', rather than what actually does work." The anarchy of the internal market in health is having a devastating and destructive impact in London.

Similarly, with the internal market, trust and health authority debt, which is caused by Government underfunding, is driving down London's health service. My own health authority, Redbridge and Waltham Forest, has a deficit for the current year of £7.2 million. Its recently published purchasing intentions show that the deficit for 1995-96 could be £9 million on top of the £7.2 million. That has serious implications, which could lead to trust mergers.

Following trust mergers always comes so-called rationalisation, with much health care being scrapped. Perhaps even the newly built King George hospital, which is already running at under-capacity despite local waiting lists because of its own debt problems, could be closed, or--horror of horrors--even Whipps Cross hospital in my area could be on a future agenda if the debt keeps recurring. I promise Ministers that, if Whipps Cross is threatened with closure, there will be a bitter battle which will make the recent M11 protest in my constituency seem like a tea party.

It is not just district health authority debt. My local community health council says:

"Forest health care trust will lose £1 million yet it is expected to increase activity by 7.5 per cent. We are very aware of the increasing pressure on Whipps Cross hospital and other FHT services due to previous rounds of efficiency savings'. We consider that these have

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already led to a decline in the quality of service and would vehemently reject the suggestion that more cuts can be made without seriously damaging services."

Debt drives costs right across London. Brent and Harrow has budget cuts of between £5 million and £15 million. Camden and Islington faces a possible £27 million cut in its annual budget. Merton, Sutton and Wandsworth faces an estimated £17 million budget cut. The debt problem is chronic, but it is the Government's tool to run down our health service and close hospitals.

Since 1990, a fifth of the capital's accident and emergency units have closed--12 in the past four years. There have been closures in surrounding areas also. That has increased the burden on existing A and E units, including at Whipps Cross in my constituency. A dozen more could close. Harold Wood hospital in Havering has already been closed, they say to be refurbished, but when it is reopened, the busier A and E at Romford's Oldchurch will close.

Bart's is due to close in January, despite massive objection. There are plans to take in Central Middlesex, Edgware, Mount Vernon, Hammersmith, Ealing or West Middlesex, Queen Mary's at Roehampton, Chase Farm or North Middlesex, Queen Elizabeth at Hackney, Whittington or the Royal Free, and Guy's. Between them, those units handle 500,000 casualties per annum.

Mr. Duncan Smith: I know that the hon. Gentleman would not wish the record to be incorrect, and that he will come to this matter. Whipps Cross, which is in the hon. Gentleman's constituency and which serves my constituency, has a spending programme of between £23 million and £27 million, which includes improvements to A and E and new theatres, new treatments and specialisms. I am sure that the hon. Gentleman will want to make that point absolutely clear.

Mr. Cohen: The hon. Gentleman is jumping ahead of my speech. Spending money on hospitals does not stop the Government closing them down later.

There has been no specialty review of casualty services, and no London-wide plan. Piecemeal cuts and closures which are proposed by a dozen health authorities and trusts could decimate London's already depleted casualty services. A and E units need to be in close proximity to the populations they serve. If people have to travel further for emergency treatment--units that are open are more heavily burdened--lives will be lost. The Government should halt all further A and E closures in London, including the closure of Bart's. I shall say a word about Casualty Watch. I saw its press release earlier this year, entitled

"Londoners left lying on trolleys in capital's casualty crisis." It mentioned that 58 patients had been lying on trolleys for more than three hours in 13 hospitals. One man had been on a trolley for 24 hours. A 92- year-old man had been on a trolley for seven hours. The press release quotes Ross Levinson of the Greater London Association of Community Health Councils as saying:

"If London's A and E departments cannot cope on a mild April day, they certainly could not cope if there was a disaster in London, or even on an ordinary winter's day."

We need to stop A and E closures.

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The London ambulance service, in its current form the creation of the Government, is probably the worst ambulance service in the country, and among the worst in Europe. The LAS achieves its target of attendance within eight minutes of an emergency call in only 11 per cent. of cases. It answers only 68 per cent. of 999 calls within the target time of 14 minutes. It has never recovered from the computer crash in November 1992. The chairman had to resign after an independent inquiry blamed management, talking about

"failures for trying to introduce an untried system against an impossible timetable."

I recall the Secretary of State blaming the workers at that time. Of course, the Government have done so again in the tragic case of 11-year-old Nasima Begum. The first call for the ambulance in her case was at 10.41 pm. The ambulance eventually arrived, after four calls, at 11.34 pm. She was in hospital at 11.38 pm. Fifty-seven minutes had elapsed, and the doctor said that they were 37 minutes too late to save her life. Only seven manned ambulances were available, instead of the 13 that should have been on standby that night, and in the confusion one available ambulance in Newham was overlooked.

Even worse than that, an LAS spokesman said:

"We are not in a position to say that this won't happen again". That is shocking. The Minister has promised more money for staff and ambulances. Let us hear of that in detail today.

Morale is a problem. Staff levels have been cut by 20 per cent. in the past decade. The Government should work with the trade union UNISON on the basis of its submission to the Health Select Committee of June this year to get the LAS back on its feet.

The Government place the emphasis on general practitioners, but they have done far too little in that area. They have given nowhere near the £250 million recommended by the King's Fund in 1992. The amount that they have given is a drop in the ocean when set against the impact of hospital closures. The Tomlinson report said that £140 million was needed just to bring all GP surgeries up to minimum standards. The way in which, and the extent to which, the Government are switching resources from hospitals to GP services received the thumbs down at the British Medical Association conference earlier this year.

The Guardian said that there were

"1,000 substandard GP practices in the capital--some are even without hot running water, let alone a practice and there are probably tens of thousands of people the GPs fail to reach--including students, squatters, the homeless and those in temporary accommodation."

A lot needs to be done to improve GP services, without the added burden imposed upon them by hospital closures.

The Government have spent some money, but its impact has been ineffectual. In its submission to this debate, the Royal College of Nursing said:

"The Government announced that it would invest £40 million in 1993/94 and an additional £85 million in 1994/95. However, there has been little tangible evidence of where money has been spent and what changes have been effected in London. Beyond the updating of some GP premises, evidence is lacking on the real improvements to primary care services."

The number of GPs per head of population is low. What are the Government doing to train and recruit more GPs? Not very much. The GP fundholder system creates a

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two-tier system that is unfair. Under that system, going for the "cheapest option" has a tendency to force out "clinical objectivity".

Far from tackling the serious problems that GPs face, the Government are just about to alienate GPs again with their performance-related pay proposal, which is irrelevant in London in the circumstances that I have described. Outer London has suffered under the Government. Both Tomlinson and Secretaries of State have said that outer London would benefit from inner-London reductions, but it has not. It has suffered huge debts, large waiting lists and repeated cuts in treatment provision. There is a real danger of hospital closures spreading out to outer London.

In my area, covering Redbridge and Waltham Forest, there is no surgery other than for emergency treatment, and urgent cases of people having babies and patients who have waited for more than 18 months. There is no elective surgery. People on the waiting list must wait 18 months, perhaps in pain and anxiety, before they can receive treatment.

The crisis is spreading. It is not just in inner London; it is outside London as well. Essex's waiting lists grew by 30 per cent. in the 15 months to November 1993. Waiting lists grew by 20 per cent. in the home counties over that period, despite London's hospital closures. The Government NHS policies overall are to blame for the cuts throughout London and outside it.

Waiting lists are soaring; 100,000 is the official figure, but the number of people who are affected is much higher. Many people are on the pre- waiting lists, which I referred to earlier. My local GPs are calling for an independent inquiry into waiting times and rising waiting lists. In Waltham Forest and Redbridge, there was a 52 per cent. rise last year. Figures in the latest district health authority papers of 31 July show that 15,289 people are waiting for treatment. That is the position across London. Waiting lists for the New River health authority area, covering Enfield and Haringey, were up 45 per cent. in the eight months to May 1994. In Barnet, they were up 8 per cent. in that period. Since Northwich Park hospital, located in Barnet, achieved trust status, waiting lists are up by 48 per cent. In Camden and Islington, waiting lists are up by 16 per cent. In East London and City, which has followed the Government's guidelines and has extra cash under capitation, 13,000 people are permanently on waiting lists. Of course, there is no wait for people going into private hospitals.

Mr. Oliver Heald (Hertfordshire, North): The hon. Gentleman keeps talking about the number of people on waiting lists, but what about waiting times? They have fallen, have they not?

Mr. Cohen: The pre-waiting list time is still extremely high. The Government have fiddled the figures. In the past, we had clear figures because they were made up of deaths and discharges--people coming out of hospitals; now we have finished consultant episodes. A patient could be shuffled around between lots of consultants before he receives treatment and the Government can say that a lot more treatment is being carried out, but that is not the case.

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The Government have wasted money on the internal market and on managers. For example, £140 million has been spent on the Philip Harris House hospital wing at Guy's. Since then, the Government have announced that Guy's is up for closure. At Chelsea and Westminster, there is a £200 million showpiece hospital. The beds there were left deliberately empty, despite high waiting lists.

In July this year, the Evening Standard talked of the Government being prepared to spend £200 million to speed up the closure of Bart's. The London Implementation Group, set up by the Government to enforce the changes and closures, has a £200 million annual budget, with a former Tory Member of Parliament as its chairman. All its meetings implementing the closures are held in secret. There are other issues that I have no time to go into.

Mr. Duncan Smith: Will the hon. Gentleman give way?

Mr. Cohen: No, because I want to finish my speech.

The nation's medical research and development is at risk. The Brentwood blood transfusion centre is to close. I have written to the Government about that. They say that a new computer system is to be installed. I hope that it is not another London ambulance service. Through the crisis, the Government have ploughed ahead in a blind dogmatic way. The views of patients, doctors, nurses and Londoners have been ignored. Far from making London better, the Government's policies are leading to an extremely sick service for London. A large majority of Londoners are extremely worried about the rundown of their NHS and the Government should heed their voice and alter course. The chief executive of the King's Fund said:

"there should be no more acute bed reductions overall, and great care about A and E Departments."

At the very least, the Government should introduce a moratorium on all further bed reductions and hospital and casualty closures. There should be an independent inquiry into the position in London. The system should be moved away from its cuts and market mentality to one that provides proper health care, which Londoners need and deserve. Several hon. Members rose --

Mr. Deputy Speaker (Mr. Geoffrey Lofthouse): Order. No fewer than 29 right hon. and hon. Members hope to take part in the debate. It is a tall order to get everyone in, but it would be helpful if hon. Members would bear it in mind that brief speeches would be of some assistance.

10.8 am

Mr. Peter Brooke (City of London and Westminster, South): I must immediately express appreciation to the hon. Member for Leyton (Mr. Cohen) for having provided so uncontroversial a vehicle for me to work my passage back as a Back-Bench contributor. In the diarrhoea of language that is contained in his motion, there was no reference to an independent inquiry. For a moment, I had hoped that sanity had overtaken Opposition Members, but I notice that, in his closing paragraph, he said that, although such a reference had been omitted from the motion, he still wanted to have an inquiry. I shall come to that at the end of my speech.

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Although I welcome the breadth of subject that the hon. Gentleman has afforded us in this debate, I hope that the House will forgive me if, after nearly 15 years of Trappism on constituency matters, my speech has a constituency bias, particularly in the direction of Bart's. However, I hope that I can frame it within the London-wide perspective.

I doubt that Kremlinologists will crawl over my speech for evidence of disenchantment with the Administration that I have just left, but if any such is detected, I hope that it will be correctly imputed to constituency concern rather than to any general bile, which I do not remotely feel. I am delighted that my hon. Friend the Minister of Health will respond to the debate, and I welcome him to the Dispatch Box.

I stress that I support the overall thrust of the policy which my right hon. Friend the Secretary of State announced in February 1993 under the title "Making London Better", which was substantially derived from the analysis of the Tomlinson report. I am not a blind admirer of that document, especially of its detail, but I support the central pillar and principle of my right hon. Friend's policy. I would do so even more enthusiastically in the light of evidence that the Government were prepared tactically to modify the application of the policy to reflect practical developments in the two years since Tomlinson reported.

Secondly, I am profoundly sympathetic to my right hon. Friend for the damnosa hereditas that she was bequeathed in London by decades of Ministers, although I accept that her immediate predecessor, my right hon. Friend the Minister of Agriculture, Fisheries and Food, had set his hand to the London plough. Perhaps I may illustrate my right hon. Friend's inheritance anecdotally.

In my first month in the House, I was invited, with characteristic enterprise, by a surgical team at Bart's to spend 24 hours with it as a proxy member of the team, so that I could understand the NHS from the inside. Towards the end of that day, when we knew each other better, we discussed the over-provision of specialties across what I think were at that time 14 teaching hospitals in Greater London. That was in 1977, and the members of the surgical team were quite adamant about that over- provision, and equally adamant that we could not expect the profession to rationalise it, but that that would have to be done by a sensible alliance of administrators and politicians working in conjunction with the profession.

Ironically, 1977 was the year in which the London Health Planning Consortium was set up to examine just such subjects, and the House will recall the studies from 1978 to 1980 on radiotherapy, cardiology and cardio -thoracic surgery and the neuro-sciences. The kindest epitaph on the consortium's work is that the quality of the analysis was superior to the results that were achieved. Therefore, I genuinely sympathise with my right hon. Friend on the scale of the problem that she inherited, which, if anything, had been compounded by the previous inertia, whatever its motivation. That stricture applies to Governments of all colours.

I also start from a position of support for the NHS reforms. Like, I dare say, many London colleagues, I winced at that unlyrical acronym RAWP, but tolerated it

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