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because of the deficiencies outside London that it was intended to resolve. Perhaps we in London sometimes underestimate the scale of improvement outside London that it has secured.

In a similar vein, I think that the Department of Health sometimes looks at London through roseate spectacles. The briefing issued to Conservative Back Benchers for this debate, which presumably emanates ultimately from the Department of Health, is written in places as if Professor Jarman and the recent analysis by the King's Fund did not exist.

I was much less happy about the quality of the NHS trans-authority accounting. Authorities in London which were treating extra-London patients were generally doing so because more sophisticated operations were required, but were being compensated for them at average rather than actual cost, and often up to two years late. That meant that our constituents in London were effectively doubly subsidising the constituents of colleagues from outside London. In principle, the NHS reforms correct that unfairness, although I acknowledge that it is contingent upon the thoroughness of our accounting.

That was the background against which developments at Bart's have taken place. This remarkable hospital, derived from and still underpinned by an inspirational Christian tradition, responded to the challenge set for it by Tomlinson--and, in due course, by the Secretary of State--in a spirit of genuine collaboration. The impressive recent financial figures which Bart's has provided give the lie to the financial pessimism expressed by Tomlinson. I note that my neighbour, the hon. Member for Hackney, South and Shoreditch (Mr. Sedgemore), nods his assent. I hope that the Minister will acknowledge that, while recognising that the game has moved on. [Interruption.]

The game has moved on in the sense that Bart's has had discussions with its partners in the Royal Hospitals trust about the best way to merge their combined strengths, although historians may well wish to comment on whether cutting the umbilical cord between Bart's and the Homerton was in the best interests of patients in Hackney. Historians will no doubt also evaluate the comparative strengths of Bart's and its partners as they approach the merger.

Before I entered the House, I made my living from the interaction of human beings in organisations, and I would have predicted a greater chance of success, especially when so historic a site as Bart's is involved, if significant disengagement from the Bart's site had been accompanied by a proportionate generosity elsewhere towards those who were joining them from Bart's. I say that especially in the light of the talent that will be coming, and I express a general doubt as to whether that magnanimity has so far been greatly in evidence.

Critical both to the merger and to my right hon. Friend's place in NHS history is that it should be carried through successfully. That in turn depends upon excessive attention to morale rather than to a seemingly casual neglect of it. Leadership of an army in temporary retreat calls for skills and character of a high order. I mean no personal disparagement when I say that I doubt that leadership of that quality is currently being deployed. The test of history will be how many of the great strengths of Bart's will survive to infuse and enthuse the new body. The departure of clinicians, academics and leaders of teams of the highest quality will be a vivid and morbid verdict on the outcome.

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Of course buildings, traditions and ambiences contribute to the morale of organisations, but in the end human beings working together in a common endeavour are the true glory.

It was in that somewhat queasy atmosphere that the announcement in late July that the period of transition would be foreshortened from the previous estimates of between eight and 15 years to six years--I have seen five years quoted--struck such a further body blow. I hope that the Minister will devote an adequate amount of his speech to why this most deleterious abbreviation was suddenly imposed, and by whom. It is difficult to imagine a shock more calculated to depress morale at precisely the moment when morale needed to be built up. Given the present public expenditure pressures and the huge backlog of repairs at the Royal London, which I have seen put at £37 million before the capital demands of enlargement are even tackled, foreshortening of the programme necessarily--or perhaps more correctly, unnecessarily--exacerbates apprehensions. Despite my right hon. Friend's uncharacteristic levity about the hospital's heritage, she belongs to a party which on the whole venerates institutions that have been 800 years in the making.

Mr. Duncan Smith: I am following my right hon. Friend's theme. In my area and in most others, there is tremendous sentiment about Bart's, which is considered to be a local hospital. Some of the decisions about the ending of some of its services and moves to the London work against the grain, and there is a feeling that the rationalisation might have been better at Bart's than at the London.

Mr. Brooke: I am grateful to my hon. Friend.

Those apprehensions are that a great hospital is being surrendered into a structure that will not even be the sum of the constituent parts, let alone something greater. The capital figures which I have heard quoted by the Department seem to allow nothing for the extra medical education costs.

I shall not dwell on the accident and emergency decision at Bart's, except to say that the heart of London has a concentration of employment which makes me regret that the City's willingness to make a private sector contribution towards a unique opportunity in a working population in my constituency which exceeds the national average by a factor of 17 was not encouraged.

Secondly, I hope that those notorious isochrones about which the hon. Member for Newham, South (Mr. Spearing) may well speak in the context of the ambulance service have again been tested since the City erected its ring of plastic, the difficulties of whose recent penetration are familiar to all those who travel to and from the City.

It was moving, earlier this week, to meet the most desperately wounded and injured of the Baltic Exchange victims and to know that he owed his life to Bart's being open. We cite Timothy Evans in capital punishment debates-- nothing I know of Aesculapius suggests that he would have regarded a single life as immaterial.

I have said enough about this constituency matter, provided that my hon. Friend the Minister speaks about it at decent length in his reply. I am confident that he will reassure me. If he does not, I can only say that I have sat in this House long enough to remember the disruption of

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business achieved by my former parliamentary neighbour George Cunningham in support of St Mark's hospital in his constituency. But those are the thoughts of a pessimist. I am an optimist, given what, at this juncture, a little imagination by the Department of Health can achieve. Fairness is a British characteristic that would serve my hon. Friend well as a watchword in these matters. I said earlier that I would come back to the speech of the hon. Member for Leyton. On the wider issues and Labour's demands, I hope that my hon. Friend will resist the specious demand for another independent inquiry, which is a predictable recipe for paralysis--but that, acknowledging the maldistribution of beds in London at this time, both geographically and by character, and allowing for reallocations between categories, he will see virtue overall in halting the loss of beds in London until we are confident that we have reached equilibrium. It is difficult to provide a regional health service, let alone a national one, if there are not enough beds with which to do it.

For myself, I found persuasive the sober language of the King's Fund report during the recess on the subject of bed closures, although I can tell my hon. Friends that it does not unreservedly apply Professor Jarman's analysis. I look forward to hearing what my hon. Friend the Minister has to say about it.

10.21 am

Mr. Peter Shore (Bethnal Green and Stepney): The right hon. Member for City of London and Westminster, South (Mr. Brooke) made an interesting speech. His concluding remarks, in which he called for a halt to the closures in London, were quite remarkable and not at all consistent with the line being taken by Ministers at the Department of Health. His remarks were supportive of my hon. Friend the Member for Leyton (Mr. Cohen), who has given us the opportunity to debate this important subject.

We are trying to be honest about what is happening. The original King Edward VII Trust report in 1992 and the Tomlinson inquiry, which was greatly influenced by the report, seemed to show that there was first, an excess of beds, and secondly, an excess of expenditure in London compared with the rest of the country. However, since then the statistics on which those conclusions were based have been eroded and undermined to the point where they lack any credibility.

I am not forgetting Professor Jarman, but the last two King Edward VII Trust reports are far from the original starting point in the whole miserable procedure of closing and rationalising London hospitals. Indeed, the last report says that London, far from having £80 million of excess resources that it should not have had, is £200 million short of what it should have were its needs to be properly assessed. It is no accident that the whole basis of

allocation--weighted capitation money--throughout the country is now being re-examined. From what I hear, that is likely to produce very different results and an increased weighting in favour not just of London, but of inner-city areas generally.

What the Government forget about entirely is the whole underlying philosophy and thought behind an inner-city policy and the whole problem of inner cities, which is not just confined to London but occurs in many of our conurbations.

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I do not want to speak at great length about the general problems of London; instead, I want to concentrate on the London ambulance service, which is a particular problem that affects 7 million Londoners. I have a special interest and concern because two of my constituents--11-year-old Nasima Begum and Abdul Barik, a pensioner, the first suffering from renal failure and the second from a heart attack--had to wait 53 minutes and 45 minutes respectively for an ambulance to reach them. I do not know whether they would have survived had the ambulances reached them sooner and transferred them to the Royal London hospital in Whitechapel. However, I do know that the waiting times for both of them were far too long and far above the guidelines published by the Government in their patients charter.

As the House knows, the charter requires that 50 per cent. of emergency calls should be answered within eight minutes and 95 per cent. within 14 minutes. It is a matter of regret that for the past five years only 63 per cent. of emergency calls--not 95 per cent.--have been answered within 14 minutes by the London ambulance service. The service has not just failed to improve: its performance has declined quite markedly from what it was as recently as the mid-1980s. Many warnings have been given to Ministers during recent years, both from Labour's Front-Bench spokesmen and from many Back Benchers, including my hon. Friend the Member for Newham, South (Mr. Spearing), who has frequently raised the matter. There is little doubt that the LAS has been seriously underfunded during recent years. In our previous debate on 28 April, the Secretary of State acknowledged the shortfall by pledging an additional £14.8 million expenditure in the current year. Looking further ahead, she said that the number of paramedics now in place- -400--would rise to 1,000 in 1996 and that the ambulance fleet would be enhanced and renewed. If those measures are thought to be necessary for 1996, it is a fairly obvious admission that the service is seriously underfunded and under-resourced now. The 53-minute wait that poor Nasima Begum had to endure has moved the Secretary of State sufficiently for her to announce an inquiry. In her letter to Mr. William Wells, the chairman of the South Thames region, which was published on 10 October, the right hon. Lady asked him urgently to inquire into the particular facts behind the tragic death of young Nasima Begum and to report before Christmas. I am much in favour of an inquiry, but it would be far better were it to be conducted not by the man who was at least formally responsible for the LAS, but by an outside independent person. I am not sure that it is a task that should have been entrusted to one person anyway. Nor do I like the strong steer that the terms of reference in the Secretary of State's letter has given to Mr. Wells. It says that he is

"to look at action needed to improve the deployment of LAS staff, rostering and the timing of annual leave, the incidence of absence for sickness and any other matters you consider to be relevant." There are some other matters, one being the role of management. I do not think that even the most biased person would attribute the service's most disastrous experience, when its computer system blew up two years ago, to the ambulance men who staff the LAS.

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Then there is the role of the Department of Health. It will be interesting to know how many representations were made to Ministers about the state of the vehicles employed by the London ambulance service, and the lack of paramedics, in the years before the Secretary of State's statement to the House on 28 April. Will Mr. Wells be inquiring into those matters, too? I put that question directly to the Minister, and hope that he can give some assurance concerning the scope and nature of the inquiry that I have described. I must tell him that, unless he can give some assurances, there will be considerable and justified scepticism about the findings of Mr. Wells's report.

Mr. Spearing: I wonder whether my right hon. Friend will allow me, before he sits down--

Mr. Deputy Speaker: Order. Has the right hon. Member for Bethnal Green and Stepney (Mr. Shore) given way?

Mr. Shore: I have just sat down.

10.29 am

Mr. Nicholas Scott (Chelsea): This is not--although I must say that it slightly seems like it--a maiden speech. I look on it rather more, after 13 years, as breaking my duck in my second innings as a Back Bencher in this House. It has been an immense privilege to serve as a Minister for the past 13 years. Life in Government is demanding, but also very rewarding. It is, however, with some sense of relief that I return to the Back Benches and acquire an independence to speak--I hope on a range of issues--and can look forward to spending rather more time than I have over the past 13 years dealing with the interests of my constituents.

Those who leave office do not always do so without some feelings, perhaps, of not being quite so happy about what has happened to them. I certainly intend to give my unremitting support to the Prime Minister in the work that he has undertaken on behalf of this country. Like a former Minister of Health, Mr. Iain Macleod, who happened also to be a great hero of mine in my early days in politics, I believe that the present Prime Minister understands profoundly what the British people want but also tries to persuade them to want something a bit better for the quality of their own lives and those of their families. He is to be much admired for that.

Like my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke), I shall spend a lot of my time on matters concerning my constituency, where we have three very important hospitals: the Chelsea and Westminster, the Royal Marsden and the Royal Brompton. Of course, those are all central London hospitals. I believe that, in central London, we are making much progress in the improvement of health care, at GP practitioner level--in family doctor and community health service provision--as well as in the hospitals themselves. It was a great experience for me recently to be able to open a new health centre in my constituency; it has five GPs and a range of community nurses and other nursing support, providing the highest quality of general practice health care to my constituents and others.

I acknowledge that there is a problem over the figuring, if I may put it that way, of health needs in central London. Of course, we all have the health care of our constituents

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to look after, but in calculating the level of health care that is necessary in central London, we cannot forget some of the extra pressures, which, inevitably, are put on those services. We all know that the policy of care in the community--admirable though it is in many respects to enable people to live in the community rather than in institutions--has put on the services of central London some very considerable extra pressures.

Although I understand from my hon. Friends that that policy has been altered and considerably tightened, the number of people being discharged from institutions for the mentally ill and the mentally handicapped has inevitably led to a considerable number of them ending up on the streets of central London. They inevitably place extra burdens on health provision in the capital itself, not just in terms of their regular needs, but as a result of the accidents that sometimes happen to them because of their lack of understanding and comprehension and their tendency to drift to alcohol and drug abuse. All have placed considerable extra burdens on the hospitals in central London.

In addition, central London has a large number of overseas visitors who from time to time will need extra health care. I believe that all those factors have perhaps not attracted the consideration that they deserve as we do the figuring for health needs in central London. The Chelsea and Westminster hospital was and is an expensive hospital. It is, however, a marvellous hospital. I must have visited it 10 times since it was opened, and I believe that the enthusiasm and commitment of the staff and the quality of provision there will ensure it a glittering and important future. I must underline and emphasise the tremendous contribution made to it by those who came from the former Westminster hospital in terms of their commitment to their new hospital and in terms of the ethos and tremendous traditions that they have brought into the new institution. I commend all those who are playing their part in developing the contribution that they can make to health care, not just in my constituency, but in central London more generally.

I am particularly concerned about the pressures that exist at the moment in relation to the future of London's health services provision to relocate both the Royal Marsden and the Royal Brompton hospitals, which are an important part of my constituency. The latter, for personal reasons, has a particular place in my heart. Both became self-governing trusts in April this year. They have shown themselves capable of rising to the challenge of proving themselves to the internal market which we now have, and are seizing the opportunities provided to them to shape their own future and respond to patient choice.

Both of those hospitals are leading international centres of excellence. The Royal Marsden, in collaboration with its associated institute, the Institute of Cancer Research, plays a world-leading role in combating cancer, developing new anti-cancer drugs, surgical techniques and new approaches to radiotherapy treatments. The Royal Brompton, with its associated body, the National Heart and Lung Institute, is the United Kingdom's premier hospital for the research, diagnosis and management of heart and lung disease in adults and children. Its research in those fields positions it as a leader in Europe and further afield.

I very much hope that the region and the Department will look carefully and sympathetically at the plans that the Royal Brompton is now putting forward for the

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construction of a new clinic on its present site, to help it to continue its ground-breaking work in the fight against the nation's biggest killer, heart disease. I am convinced that the concept behind the clinic represents the next logical step for the hospital, and, of course, it is supported not just by those concerned directly with the hospital but by the major purchasers of its services. Rapid advances in new technology and treatments now mean that the clinic will not involve provision for additional in-patient beds--which may be of concern to some hon. Members--but they will meet patient choice increasingly with the provision of ambulatory care and day-case treatment.

The Royal Brompton, like other hospitals in London, has been the subject of intensive reviews by various agencies over the past few years. The 1993 cardiac specialty review recognised that the hospital should be the leading centre in west London. Its clinical research has a high reputation. The research assessment exercise by the Higher Education Funding Council for England, in December 1992, gave the Royal Brompton's sister organisation, the National Heart and Lung Institute, the highest possible rating for research of national and international calibre.

My right hon. Friend the Secretary of State for Health has characterised the 1990s as a decade in which to harness the energies of private enterprise to the good of our great public services, not least the national health service. That is an exciting and innovatory approach, and the public and private sectors are keen to support the Government in taking that step forward.

The Brompton clinic has the potential to be a first-class contributor to that concept. The intention is that it would be built at little or no additional cost to the taxpayer through the use of the private finance initiative. That would be a new departure for the NHS, but I emphasise that the clinic would be part of the health service. It would be one of the first health care projects of such a size to be funded using the private finance initiative. Private developers would provide the new clinic in return for the opportunity to develop certain other properties on the Royal Brompton site. In the past, the private sector has sometimes been critical of NHS managers and officials for what is perceived to be their overly cautious approach to such joint ventures. Now, an innovative hospital trust has developed the basis for a sound partnership with the private sector. We cannot afford to see that falter because of old-style bureaucratic controls, which would be wholly contrary to the concept of the reforms that my right hon. Friend the Secretary of State introduced. Approval of the scheme, which has attracted considerable interest from the private sector, would send a clear signal from the Government that they are committed to expanding opportunities for partnership between the public and private sectors in the future national health service.

The Royal Brompton hospital trust is an international centre of leading- edge treatment for heart and lung disease for patients throughout the United Kingdom and Ireland. As I said, its research makes it a leader in Europe and wider afield, and its future should be considered in that international context. The Royal Brompton is not simply another west London hospital. Although it is located there, its services are essential for national and international use.

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I hope that when my hon. Friend the Minister, whom I welcome to his new responsibilities, examines the pattern of central London hospitals, he will feel able to support the Royal Brompton's plans for its clinic and to reject the rather grandiose alternative plans for health care provision in west London. The Royal Brompton has won its right to stay on merit and on merit alone.

I reiterate the point made by my right hon. Friend the Member for City of London and Westminster, South: the last thing that London's health care services need is yet another independent inquiry. That would be a recipe for further delay and uncertainty, whereas London's health service needs certainty and clarity about its future. My constituents are lucky to have outstanding health care, with the Chelsea and Westminster, Royal Brompton and Royal Marsden hospitals on their doorstep. I do not want the development of the future contribution that they can make to the quality of health care, far beyond the boundaries of my constituency, inhibited in any way by shortsightedness on the part of the region or Department of Health. I am sure that my hon. Friend the Minister, who takes a notably robust approach to bureaucratic meddling and delay, will employ those skills in the present circumstances.

10.43 am

Mrs. Barbara Roche (Hornsey and Wood Green): Nye Bevan's book "In Place of Fear", published in 1952, included the statement:

"No society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means."

By the time that Nye Bevan had written those words, he and the 1945 Labour Government had established the national health service to provide health care and the reassurance of health care to all. The present Government claim to have reformed the NHS to make it more efficient, so that it will provide a better service, but nothing could be further from the truth. They have produced a national health service that serves the bureaucrat, not the patient. This morning, I will describe the state of health care in my constituency and examine exactly who has benefited from the Government's reforms--who are the winners and who are the losers.

The post of chief executive of North Middlesex hospital, which serves my constituents, was recently filled by a contract with a management consultancy, Ernst and Young, under which one of its partners will perform that important role four days a week. For the services of that partner four days a week, Ernst and Young is paid in the region of £150,000 a year. Hon. Members in all parts of the House may like to ask themselves to whom that chief executive owes allegiance--to Ernst and Young or to the local people who use the hospital and rely on it for their health care?

Ernst and Young's entry in the 1994 directory of management consultants states that one of their main specialist activities is privatisation. How appropriate--and what a great basis on which to select a firm of private consultants to play a part in our national health service. I put those points to the Secretary of State for Health in a letter dated 29 September, to which I have yet to receive a reply. Perhaps the Minister will say whether he considers it appropriate for a health authority to pay a private firm for the services of one of its partners in the

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role of chief executive of a hospital trust. The public might think that the head of a hospital should be accountable to them as the local users of the service--and the losers in these so-called health reforms.

Mr. Hartley Booth (Finchley): Does the hon. Lady agree that such consultants could improve the health service by introducing outside skills and experience?

Mrs. Roche: They are certainly making a great deal of money and adding a lot of bureaucracy. I would much rather see some of that £150,000 a year spent on patient care, on doctors, nurses and auxiliaries, than on unnecessary bureaucracy.

Ernst and Young is not the only management consultancy to benefit from the current local NHS climate. Price Waterhouse has just been paid £28,000 to conduct an investigation into whether one of the two accident and emergency departments covering Haringey and my neighbouring borough of Enfield should be closed. It is not necessary to spend £28,000, which could have been spent on patient care, to ascertain whether one of two well -used casualty departments should close, particularly when one of the health priorities in the local health strategy of the New River health authority is:

"Services should be local and accessible, as close as possible to people's home, family and friends."

That is tremendous, but what will it mean in reality if one of the two accident and emergency units is closed?

When I wrote to the Secretary of State for Health about the matter, Baroness Cumberlege replied:

"clearly this study has to be paid for but this will be seen to have been well worthwhile if the review leads to improvement". What arrant nonsense that is--and what a complete waste of taxpayers' money, which could have been well used and well spent elsewhere. The noble Lady did not explain how closing an accident and emergency department could lead to an improvement. Perhaps the Minister will deal with that issue today. I recently received a letter from a very busy general practitioner group practice on the issue. It said:

"Any decision to close either casualty is gambling with human lives. We ask that you do all you can to prevent such an occurrence from taking place."

Who are the winners and who are the losers? Undoubtedly, some private hospitals and the private sector have been among the winners. One of my local health authorities has admitted that almost £500,000 of taxpayers' money was spent between April and August this year on providing private beds for mental health patients. Once again the winners are the private hospitals. The health authority also admitted that the figure will probably rise to £1 million by the end of this year and that the beds are at a considerable distance from St. Ann's, which is the hospital where mental health in-patients were treated before the health reforms. Apart from the cost to the taxpayer, it is wholly inappropriate to place patients in hospitals that have no links with the local community in which they will live when they are discharged. Once again, it is the patients who lose.

Other private firms also benefit. When the New River health authority--my local authority--issues press releases on its various initiatives, the contact number at the bottom of the release is not that of the health authority but a public relations firm in St. Albans. I wrote to the chief executive of that health authority asking him about its contract with the firm and how much taxpayers' money

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it costs. He replied to my letter, but for some unaccountable reason omitted to give me the figure. I wrote again asking him to remedy that omission, but to date he has not replied.

Once again it is the public, as taxpayers, who lose. What guidelines has the Minister's Department issued to health authorities about the amount of public money that they can spend on buying in public relations? My hon. Friend the Member for Sheffield, Brightside (Mr. Blunkett) recently established that management costs in the national health service have risen by 1,800 per cent. in five years and that this summer at least £37 million was spent by 143 trusts on logos and image building.

I was delighted to hear that the new Minister of State is renowned for his attacks on bureaucracy and his abhorrence of bureaucracy and waste. I trust that when he addresses the House today, he will respond to my arguments.

When I visited one of my local hospitals recently, I was interested to be introduced to its new director of marketing. I wonder how many other such directors there are in the country. It is obviously a growth industry-- people moving from the private sector to the NHS to be directors of marketing. How much of that contributes to the battle against bureaucracy and waste and to the improvement of our national health service?

How absurd for the Secretary of State to say at her party conference last week:

"While I'm Secretary of State, bureaucracy will have no hiding place".

Yet our national health service is the place where bureaucracy and waste flourish. Meanwhile, patients are suffering because the simple truth is that in our health service, under the uncontrollable monster of the internal market, the money is certainly not following the patients.

One of my constituents had been on a waiting list for a hip replacement operation at a central London hospital for three years. She came to my surgery, walking with sticks and in obvious pain and distress, to tell me that because the New River health authority did not have a contract with the central London hospital she had had to start again on a waiting list at another hospital. Fortunately, because of lengthy representations that I and others made, the health authority agreed to make an exception in her case. How many other patients who have not managed to contact their Members of Parliament--I am sure that many of my hon. Friends who speak later will give other examples--have been placed in such an appalling situation simply because the needs of patients did not fit in with the internal market system?

Let us take another example. Between 1990 and 1992, another constituent was treated at the Middlesex hospital for severe neck and shoulder pain. During her treatment her condition was carefully assessed and, thanks to the excellent consultant with whom my constituent built up a good and trusting relationship, the condition became manageable and she was able to stop attending the hospital. When things went wrong again this year, her GP wanted to refer her to the same consultant who had helped her last time, but found that he was no longer allowed to send patients to that department. In the words of my constituent:

"Instead of being seen in a clinic where I have built up a relationship with the doctor and which knows my history I must start all over again from the beginning at a new hospital. Some

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choice! . . . This would not be worth writing to you about if it was a lone case. Sadly I suspect that there are thousands like me who have lost their patient choice' with the NHS changes".

That is some choice and some situation when the Secretary of State says that money follows the patient, but clearly it does not. That is the reality of the national health service in London today. In the words of a former member of the NHS executive, it is a "total shambles".

Today's national health service is like a national lottery. Ordinary people, patients, taxpayers and the long-suffering public know that they are the losers in the reforms and that the Government's friends--private firms, private hospitals and highly paid consultants--are the winners.

Mr. Duncan Smith : On a point of order, Mr. Deputy Speaker. I am aware that time is short and I will not detain you. My point of order arises from an answer during Agriculture questions yesterday. The matter is critical. There has been a report today that the Government are indicating that they may not pursue a court case against the Italians, which involves about £2.3 billion in fines. Yesterday, the Minister of Agriculture, Fisheries and Food said clearly in answer to a question on the subject that the Government had no such intention; yet today we hear that report. Have you heard from the Government that they intend to make a statement about a change in their policy on that matter?

Mr. Deputy Speaker: I have not been notified of any intended statement.

10.59 am

Dr. Ian Twinn (Edmonton): I should first declare my interests in health care: I act as adviser to the Chartered Society of Physiotherapy and to the British Surgical Trades Association. Neither body has given me any advice about today's debate; I speak purely as an outer London Member of Parliament.

Conservative Members are grateful to the hon. Member for Leyton (Mr. Cohen) for raising this subject. As he can see, there is a wide range of interest in the health service in London.

I sometimes sit through these debates and listen to Opposition Members commenting on the same regions, hospitals and health service as us. They appear to see nothing but evil and harm in London's health service, whereas Conservative Members can see not only the problems, which we are tackling, but the great achievements. It would have been nice to hear not only criticism but some praise for the health service from Opposition Members.

Throughout the country, the Government have achieved their prime objective for the health service of putting patients first. The health service in London and elsewhere must be about providing the best possible health care within the resources of our nation and not about working for the entrenched interests of various bodies in the health service. The health service does not exist to serve the interests of those who work for it, although as a responsible employer it must take into account best employment practices. I therefore approach reform of the health service in London rather differently from Opposition Members, but I am glad that they at least appear to accept that there is a case for doing something about the health service in

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London and that reforms are necessary. We can all agree that the state of the health service is not acceptable and that we wish to see improvements and changes made.

Change in itself can be disturbing. For example, it can result in the loss of facilities that people have grown used to. Sometimes decisions will have to be taken that will result in the loss of institutions that we have grown used to. I recognise the point that my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke) made--that our venerable institutions of health care in central London have served the nation well for 800 years, but that population patterns change and so the health service must not be too attached to buildings or to patterns of health care that were relevant in the last century and up until the second world war, when the population density of central London was very high.

People have moved out to Wood Green, Edmonton, Chingford, Bromley and Croydon, where the population density is now much higher yet the provision of health care has not followed that population. As an outer London Member of Parliament, I am concerned to ensure that we get our fair share of resources and I was excited about the reforms, which proposed moving resources to where people live.

Mr. Peter Bottomley (Eltham): Further to the point that my hon. Friend is developing, which applied mainly to acute services, does he agree that one of the problems in inner London, which has been identified in many reports over decades, is that inner Londoners have been suffering from an absence of community services of any quality and that GP services do not match those that outer Londoners have taken for granted?

Dr. Twinn: Indeed. I sometimes have difficulty with the distinction between inner and outer London. I have never accepted that there is such a concept as the inner city, which is deprived, and the suburbs, which are not deprived. As a planner who formerly lectured in town planning, I knocked my head against the brick wall of Government and fellow planners who grasped simple ideas of the inner city and consequently built their policies around a misguided concept. My constituency is part of the industrial Lea valley, but inner-city factors extend out beyond my constituency into the Enfield, North constituency, areas of which are, in effect, inner-city areas.

One of the reforms in London has increased spending. The Government considered where resources should be put, and money is being put into primary care. I want much better primary care for my constituents, and investment is beginning to be made in GP practices and community health facilities. The hon. Member for Hornsey and Wood Green (Mrs. Roche) mentioned the accident and emergency department at North Middlesex hospital, which has been under threat, but I am pleased that the health authority is funding a GP for the department so that people who, perhaps wrongly, have looked to their general hospitals for primary health care can now see a GP and not take up the scarce resources of specialists in accident and emergency, which are needed for people who are genuinely suffering trauma from accidents or emergencies.

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I should like those facilities to be expanded. At present, they are available only during the day. I recently visited North Middlesex hospital late on a Saturday night to see how it was working. Many of the patients to whom I spoke were waiting to be seen by specialists, but they could have been seen by a practice nurse or a GP working late at night, rather than wasting the time of people who are highly trained in dealing with accidents on the M25, the A10 or the north circular road, all of which the hospital serves.

I am pleased that as a result of our reforms money is beginning to follow the patient. In London, Bart's is regarded as a local hospital as well as a national teaching and specialist hospital. I was pleased recently to accept an invitation from Bart's to attend the North Middlesex hospital, where it has opened a clinic for renal treatment. Patients who previously had to troop down to central London for dialysis can now be treated at the North Middlesex. That is a welcome move. I hope that soon clinicians will follow and Bart's patients will be able to see their consultants at the North Middlesex. There is a great future for Bart's in moving out to the community, serving people who used to look naturally to it as their first choice but who can now look to hospitals such as North Middlesex, where the expertise of Bart's can be provided without losing the specialist nature of the Bart's team who, working together, make a special contribution to health care in London.

Teaching hospitals are not always on the side of the angels in these matters. A few years ago, I came to the House of Commons to argue for the protection of our local radiotherapy department at North Middlesex hospital. It was under threat because one of the large teaching hospitals in London believed that it should have all the money spent on itself. I am pleased to say that the Department of Health and Ministers listened to our arguments, so instead of my constituents and those of the hon. Member for Hornsey and Wood Green being dragged daily on hazardous ambulance trips to London they can have their radiotherapy at the North Middlesex, where facilities have been invested in and expanded. I am grateful to the Department for doing that.

Money is going to where patients live, but perhaps the House will forgive me if I deal with the point that the hon. Member for Hornsey and Wood Green made about accident and emergency provision in north London. Two accident and emergency departments cover my constituency. Chase Farm hospital, on the green belt borders in north Enfield, covers a large area of north London, extending out into Hertfordshire. The other department is at the North Middlesex, which is in my constituency but on the border with Tottenham. It serves the population of Tottenham, Wood Green, and Palmers Green, which is in the constituency of the Secretary of State for Employment, my right hon. Friend the Member for Enfield, Southgate (Mr. Portillo). It also covers areas of east London and Essex, where the north circular road provides speedy access to the accident and emergency department, and it will be even speedier when investment in the north circular road improvements is complete and my constituency is again open for business.

I was worried when I heard that the New River health authority, which is a monopoly purchaser--there is no other choice for hospitals--decided that two accident and emergency units were unnecessary and that one would suffice. I must say that I am not critical of reports in

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general. It is important to examine the provision of health care objectively and to see the facts and figures, although we have not been able to do so in this case. I look forward with interest to seeing the report. I suspect that, had the report been conducted in-house by the national health service, it would have cost a great deal more than has been charged by the private sector. The specialist knowledge of the firms involved means that they can make a useful contribution to the health service. However, I do not believe that the two accident and emergency departments cover the same area. One of the problems that has bedevilled the national health service for many years has been the regional, district and area boundaries. Some of the more ludicrous locational decisions about hospitals in the London region have been made because there were four Thames regions whose boundaries have been treated as though they were international divides. Investment was sometimes made in hospitals close to regional borders, and it seems that the Department of Health has not exercised due care and attention in relation to the planning of hospitals in the London region for many years. That has been true under Governments of both parties. We now have only two Thames regions, so the problems may diminish. However, I am not convinced that the north-south divide in London will not lead to some unfortunate decisions about which teaching hospitals should or should not survive. I hope that the Minister will be able to clarify that point.

I believe that we are about to see the same mistakes being made by purchasers as were made by the regions. The New River health authority, which covers the two London boroughs of Haringey and Enfield, is treating its boundaries as all-important and is behaving as though its hospitals did not provide services to people from elsewhere. If the Minister is to allow the New River health authority to make decisions about accident and emergency provision in my constituency, without reference to the services that can and should be provided to a much wider area, we shall lose the services of an accident and emergency department which should not be lost. I welcome my hon. Friend the Minister of State to his new post and ask him to give an undertaking that no purchaser--let alone the New River health authority--will be allowed to make such decisions without a strategic review being made of services throughout the entire London region. I am talking not only about Greater London but about a much wider area. Sick people do not recognise health authority boundaries, although sick minds may sometimes do so when taking planning decisions. However, I cannot ignore my training as a planner, the interests of my constituents or my common sense, which all tell me that the care of London is being planned in a nonsensical way. Although I broadly welcome the reforms in London--I am not against the Government moving money and resources to outer London hospitals, and I am very much in favour of co-operation between outer London hospitals and centres of excellence such as Bart's--I want the Government to exercise restraint and ensure the sensible planning of facilities in outer London.

11.13 am

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