House of Commons Hansard Debates for 21 Oct 1994

Mr. Simon Hughes (Southwark and Bermondsey): The debate is timely and the hon. Member for Leyton (Mr. Cohen) has done us a service by giving us a debate on the second anniversary of the Tomlinson report.

Mr. Clive Soley (Hammersmith): He also provides us with many other services.

Mr. Hughes: I agree. It is three years since that report was commissioned and two years since it reported and now we must face what it implies. I welcome the contributions by the right hon. Members for City of London and Westminster, South (Mr. Brooke) and for Chelsea (Mr. Scott). Their speeches showed that when people cease to be Ministers they can speak out for their constituents much more strongly. I am sure the Minister has noted what they said about the needs of their parts of inner London. My final tribute is to another former Minister, the hon. Member for Romford (Sir M. Neubert), who made many important points about the way in which we go about planning the process of health service decisions. He spoke mainly about his part of east London, which was also mentioned by other hon. Members.

We welcome the new Minister and I hope that today's speeches will give him the flavour of the difficult issue that he has inherited and must deal with. I certainly understand the difficulties, which were highlighted by the hon. Member for Colchester, South and Maldon (Mr. Whittingdale). As he said, one of the key debates is about the fair and proper allocation of resources across the country. The other must deal with the total allocation of resources to the health service. If the Minister looks at opinion poll evidence, whether from the Tory party research department or the general public opinion polls, he will see that the public are most preoccupied with two issues: the funding, resourcing and

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future of the health service and the general economic well-being of themselves and the country. People are saying very strongly that the health service needs more support and funding. We are soon coming to the second integrated Budget with its public expenditure announcements and the Minister should bat as hard as possible to ensure that health service funding is not reined back. NHS requests for funding must be supported.

Mr. Jenkin: Will the hon. Gentleman give way?

Mr. Hughes: No, because I want to ensure that everyone who wants to speak has a chance to do so.

I agree that there is waste. The hon. Member for Hornsey and Wood Green (Mrs. Roche) gave good examples of the way in which the newly structured health service produces waste rather than reduces it. But above all, the NHS must have the resources that it requires. Those resources are determined by need--that is to say, by the number of people waiting to be dealt with, whether they can be dealt with at the time when they need treatment, as the NHS intended, and whether there is capacity to deal with them properly in the GP's surgery, the local clinic or the hospital.

I hope that we can all agree that one of the lessons from the debate is that the health service, however big its budget, is still not adequately meeting the needs of an ever-aging community which obviously will make increasingly more demands.

The other difficulty that I mentioned relates to the allocation of resources. I have one general and one specific comment on those. If we all look at the figures honestly, there should not be significant dispute between those who represent London constituencies and other hon. Members. London receives more resources per capita for services such as policing and social services, as inner-city areas always do. There are all sorts of reasons for that, sometimes because of salaries and costs which are obviously higher in cities. I could quote from several parts of the Tomlinson report which make it clear that London as yet does not have the same standard of care for its patients as many other parts of the country.

Mr. Jenkin rose --

Mr. Hughes: As I have said, I shall not give way because many hon. Members want to speak in the debate.

No one argues that there should not be adequate health care in Essex, Sussex, Surrey or Lancashire. The argument is that the people of London and those who will inevitably continue to come to London to work or to visit or because they are referred here--not because there is no alternative, but because for them London is the better alternative--should have the correct proportionate share of the cake. There are also the extra burdens that fall on the inner capital city--the homeless, rootless people on the streets, the number of people with problems of poor mental health, and other deprivation factors.

If we look at the problems honestly and use agreed facts and figures, rather than working on prejudices, there should not be tension. It is not impossible to say that London needs more resources, but also to accept that more resources are needed elsewhere. We must not have an artificial debate.

We cannot come to a proper conclusion about this until we have a fair outcome of the review of weighted capitation which is sitting in the Department. I understand

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that it is complicated--I have been round this course many times since I came into the House and many of us understand the range of issues involved--but we cannot fairly calculate adequate provision and the appropriate figures unless a common formula is generally agreed and endorsed as valid, to which we can all work.

That is especially important in relation to London. It is nonsensical that my constituents and our local health authority have to pay more to buy services from our local district general hospital--which happens to be Guy's--than to buy them elsewhere, simply because they happen to have been born, brought up or settled in a part of London where the land costs are higher. It is nonsense to say, "We will charge you out of existence and ship you further away because the land costs for a hospital in outer London, the midlands or wherever are cheaper." Without dealing with that unfairness, we will not solve some of the other issues.

Tomlinson recommended the setting up of the London Implementation Group

"to secure effective pan-London co-ordination of a restructured NHS."

Without such co-ordination, we cannot make sensible decisions. We have already moved from four regions to two. However, people seem unable to debate the London health service as a whole except in this place. In addition, all the other people who make London's health decisions are appointees of the Secretary of State. If the debate is on a health authority, the debate is sometimes in public and sometimes in private; if it is by a trust, it is always in private. One reason why the Government are in such trouble with the health service, including in London, is that they have no co-ordinating body, with consequent absence of accountability and meetings in public. If health authorities met openly and discussed these matters strategically, there could be a consensus whereby budget parameters could be set, but accountable, and local people chosen or elected to make decisions. That would cause the Government far less political difficulty and it would be a far more democratic process. Tomlinson made three other salient introductory points. First, he envisaged that there would have to be fine tuning of his proposals. On page 1 of his report he said:

"The mechanism we propose will allow for fine tuning as events unfold."

What the Minister is hearing is, "Please don't just go by the original proposals without modification after listening to the arguments and hearing the debate."

Secondly, Tomlinson said:

"We have taken it as a fundamental that the population of London must have as high a standard of general practitioner, hospital and community-based health care as the rest of the country."

That is one of tests. The second is:

"Subject to this overriding requirement, we aim to preserve and enhance the national and international role of medical research in London and in the many other centres of the UK."

That cannot be done by saying that some of the greatest institutions--in terms not of age but of excellence--should be taken out of NHS provision.

Tomlinson's third salient point, which again came in the early introductory statements, was that he was seeking

"to build upon consensus rather than merely devising our own blueprint for action."

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I say to the Minister, for heaven's sake build on consensus and do not proceed with a Government blueprint for action that does not have the consensus of patients, those who work in the health service and those whom we serve.

When considering resources and making decisions about hospitals such as Oldchurch, Bart's and Guy's, we must look not only at the pan-London picture but at the local picture. In the Guy's case, we must look at resources in south London, south-east London and inner south-east London, which have far fewer beds than the national average in terms of population. It is no good applying to a local area a principle that is, first, questionable, and secondly, does not work within the relevant immediate community. As the hon. Member for Leyton made clear, figures and facts have changed and the evidence is different. The Treasury does not base its decisions on facts that are three years old--and heaven knows, it still does not get it right often enough. I am not claiming that we shall always need the same number of beds from now until eternity, but the decisions on bed numbers must be based on accurate facts about bed numbers. The hon. Member for Peckham (Ms Harman) and I attended the annual general meeting of the Guy's and St. Thomas's hospital trust recently. Its first annual report was produced on the day of the meeting, so no one had the opportunity to read it before then. It contained not a mention of bed figures. When I asked how many beds the trust had now, and on 1 April this year and on 1 April last year, nobody knew the answer. The trust did not know how many beds it had. That is nonsense. There must be agreed facts because we cannot make decisions about beds and expenditure in London on the basis of fallacious and outdated information or on no official information at all.

An increase in primary care in London is clearly needed. The Government have accepted that, and the London implementation zone has been set up. Many general practitioners' surgeries are poor and the quality of some general practitioners is poor. However, it is fallacious to believe that increasing expenditure and quality in primary care reduces the demand for secondary care. The evidence shows that the opposite is true. If there is better primary care, diagnosis is made earlier. More preventive health care means that more needs are identified, which then have to be referred for secondary action. It is not justified to say, "We are taking money out of the acute sector to put into the primary sector, so that means a reduction in the secondary sector."

In relation to accident and emergency provision, I hope that the Minister will please not confuse, "These are cases that could be dealt with by GPs", and "These are cases that could be better dealt with by GPs". All sorts of things can done by GPs, but that does not mean that they are things that GPs are happy to do, comfortable to do, have the equipment to do or are the best people to do. Many people will continue to need to go to accident and emergency departments for treatment and we must judge the need on that basis.

Surely the test for the Minister is whether the health service in London is working. The answer that he is hearing from hon. Members on both sides of the House is that the NHS in London is not working. The ambulance service is not working. Youngsters and old people from Tower Hamlets and elsewhere die because the ambulance

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does not come to collect them. The elective services are not working. People are still waiting for years to have operations such as hip replacements--ordinary things which hugely improve their quality of life. The emergency services are not working. People are waiting on trolleys, as the hon. Member for Barking (Ms Hodge) illustrated, and then do not get home. Primary care often is not working; there are still grim GP surgeries. Community care certainly is not working. People are often discharged into totally inadequate care. The answer is that the London health service often is not working. Our job must be to try to ensure that it does.

My last point relates to Guy's. The hon. Members for Chislehurst (Mr. Sims) and for Dulwich (Ms Jowell), to whom I pay tribute, are seeking to work with me and with the wider community to persuade the Government that the argument for Guy's to be run down is flawed. We think that we have a case which, on a rational, non-prejudiced, non-partisan basis, if the Government are reasonable and honest, will win the argument.

I know that the debate will follow and that we are about to have three months' consultation, but I will tell the Minister why we believe that we can make a case that he and his colleagues should find appealing. First, things have moved on from Tomlinson. In effect, Tomlinson proposed that it would be possible to rationalise Guy's and St. Thomas's on one site. The trust board was asked by the Secretary of State to consider that. It did not agree, and proposed that both sites were needed. On 10 February, the Secretary of State announced a strategic direction: in effect, the running down of Guy's. Eventually, three months later, we discovered that it was only a proposal, not a decision. The Chessells committee was set up and put a proposal to the trust board in September this year, but that, too, was rejected.

There is now a further modified proposal. The modified proposal that is likely to be put out for consultation--the trust's latest proposal--has already accepted that it is impossible to run everything on one site. It has accepted that we need beds on both and specialist treatment on both. It has accepted that we will need to use Philip Harris house. The only thing that it has not yet accepted as a principle is that we will need a casualty unit on both. The clinicians never said that they wanted only one site. They said only that of course they would prefer one site if everything could be provided on one site. But it cannot be and will not be, so we are now looking at only a two-site option. We believe that for the avoidance of risk and not putting the lives of patients at greater risk, the sustaining of at least the level of care currently provided, and the most clinically and academically coherent provision, which will of course mean some rationalisation and avoidance of duplication across both sites, there is a proposal that can achieve that. Coincidentally, it can achieve it at a lower capital cost than the proposal coming from the trust and at no greater revenue cost. If I were a Minister I would say, "Thank you, and thank goodness for that."

As in the case of Bart's, some 1 million people are saying that there is a need for Guy's--not just local street traders, schoolteachers and children, but Nobel prize winners from around the world, Japanese business people, and leaders of opinion such as the United States academic community are all saying that Guy's is needed. Bishops and actresses are saying that Guy's is needed. Tory, Labour and Liberal Democrat politicians are saying that

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Guy's is needed. Ministers and former Health Ministers from both sides of the House are saying that Guy's is needed.

If everybody who has looked at the issue and understands it is telling the Government that a hospital such as Guy's is needed, I hope that the new Minister will realise that the wise thing might be to follow the advice and evidence, and not to apply the prejudice which suggests that a blueprint proposing that Guy's should be run down must be applied. I believe that the Minister can do that. He will make himself and the Government hugely popular if he understands that, and today's debate will have been a seminal influence in ensuring that the Government implement health service reforms in London in a way that is much more understanding of the level of still unmet need.

12.33 pm

The Minister for Health (Mr. Gerald Malone): I thank hon. Members who were kind enough to welcome me to the Dispatch Box for the first time, in an extremely important debate.

The hon. Member for Leyton (Mr. Cohen) was doing rather well until he gave it all away at the end. As my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke) said, the hon. Gentleman called for yet another review, yet more delay. I want to set my remarks in the context of the fact that I do not believe that we can delay further. We must press ahead with the structural changes that are now in the pipeline and going out for consultation. There is no possibility of going back to square one.

If we were to hold such a debate in 2020, some things would have changed. You, Mr. Deputy Speaker, would be an even more august presence than you are today. I do not know where the rest of us would be. I imagine that the hon. Member for Leyton would have his beard restored, and that it could be snowy white. He might refer to the hon. Member for Islington, North (Mr. Corbyn), seated behind him, for advice on that aspect. I am sure that the hon. Member for Leyton will still be calling for yet another review.

I wanted to delay my intervention until the House had a chance to hear the hon. Member for Southwark and Bermondsey (Mr. Hughes). We were not disappointed. I am tempted to hand over the whole service to the bishops and actresses, who have such a detailed and concise view of it and have expressed their opinions.

I met the hon. Member for Southwark and Bermondsey when he was canvassing in the rather unlikely circumstances of the Conservative party conference in Bournemouth. Looking like a lost soul, he was walking up and down the pavement with his "Save Guy's" balloons in front of a "Kill the Bill" demonstration. The hon. Gentleman cut a relatively lonely figure, so I gave him succour and promised to listen to the important points that he made about Guy's, St. Thomas's and the future. I and my colleagues in the Department have considered the arguments with great care.

As the hon. Member for Southwark and Bermondsey said, we are entering a period of consultation. I am determined that it will proceed and be well informed, and that all views will seriously be borne in mind when Ministers consider the matter. I give the hon. Gentleman

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that guarantee. If he wants to bring his balloons to the Department to press any further points on me, he is more than welcome. London's health care problems are extremely well known. They have been debated not just since Tomlinson--which made an important contribution--but following the publication of report after report over many years. Government strategy was clearly set out in "Making London Better", published in February 1993. It is easy to agree across the Floor of the House on the motherhood principle--that we want the best health care for all and higher standards of care and, particularly in respect of primary care in London, that substantial improvements need to be made.

At times, however, we must take hard decisions. I will make the point, including to my right hon. and hon. Friends who have contributed to the debate, that, while we are given many views about that which must remain and what is best, everyone also agrees that things must change. The two are logically incompatible. There cannot be change with everything remaining the same. We must face that, and take decisions that will often be difficult and uncomfortable. Nobody--least of all in government, and certainly not me--approaches London's problems lightly. None of us fails to appreciate that any major programme of change, particularly that involving famous and well-loved and respected institutions, causes anxiety and attracts attention. Equally understandably, the reaction of many people is to shrink from the need for change and not to take difficult decisions. The instinct is to retain the status quo, but that is not an option. I was interested in remarks about funding and capitation, and I will deal with them in detail later. However, in the context of London in particular, it is clear that the capital's population has reduced significantly over the past three decades, by 1.3 million between 1961 and 1991.

One cannot have such a change in population pattern without it necessitating a change in structure. In addition, there have been many changes in practice. Some hon. Members referred to the fact that beds are the only important criterion. Everyone seems to measure the service by bed numbers, but perhaps such a measure is far too narrow. It is a little like a restaurateur deciding that his restaurant is successful simply by counting the number of seats, and not bothering about the number of satisfied customers.

The truth is that it is not only the population changes that are driving the need for the number of acute beds in London to be questioned. That is happening not merely in Britain but throughout the world. Some of the figures for acute bed reductions in other developed countries are remarkable. For example, Ireland has lost more than 40 per cent. of its hospital beds in recent years, and the same is true in the United States, where 20 per cent. have been lost in the past decade. In any developed economy with a developed health care system, much the same can be seen. There are simple reasons, and many are medically driven.

People are no longer required to remain in hospital for as long after an acute episode. They go to day centres, and hospital-at-home services are being introduced. Intermediate facilities are springing up, which I very much welcome. People move from acute beds to the intermediate service before they are finally discharged.

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The bed test is simply no longer valid as the most important element in deciding what should happen to health care and whether the reforms that have been put forward and on which we are consulting are right, well informed and likely to be successful.

Several hon. Members mentioned capitation, and asked about the Government's intentions. As hon. Members on both sides of the House know, the capitation formula is intended to ensure fairness. My hon. Friend the Member for Colchester, South and Maldon (Mr. Whittingdale) mentioned that fact, and urged us to consider the best available information when informing our decisions about future funding. I am delighted to be able to respond and to tell him that of course that is what the Government will do.

Anyone who cares to consult this morning's British Medical Journal will discover that the York report is published there. The equations are there, as well as the logic behind York. That formula will be used to inform Government in decisions taken about capitation in future. Of course it will be--it is sensible. Guidance is being published and circulated to the national health service to that effect.

That reinforces the Government's policy that money must be distributed fairly and transparently to the health service. Allocations will continue to reflect local population characteristics and health needs. Where change is seen to be necessary it will be made certain that any transition is smooth and that it is put in place without dislocation, which is extremely important.

Mr. Soley: Many hon. Members remember that one of the failings of the Tomlinson report was that he was told to consider the situation in London, and did not take into account the fact that many of our hospitals draw in patients from areas outside London. The Minister seems now to be saying that we will take that into account. The contradiction in the Government's position is that they are not clear whether they are considering the hospitals' entire catchment area, in which case the Minister is throwing out many of the figures in Tomlinson, or whether they will stick to Tomlinson, in which case he must ignore the outer London influence.

Mr. Malone: The hon. Gentleman misunderstands the position. When taking decisions and distributing cash throughout the country at regional level, the Government look at the formula that influences those decisions. The system also has many other drivers. Thereafter, when the regions distribute at a more local level, they take the needs very much into account and inform themselves on that basis. It is a complex process, and one that cannot simply be driven by a straightforward equation. One cannot merely press the button and get out an answer. It is an informed, well- established process, and it fundamentally underpins the fairness of the distribution of resources across the country. A number of my hon. Friends have rightly mentioned that matter.

Ms Glenda Jackson (Hampstead and Highgate): I am nterested in the Minister's statement that there will be a fair distribution of health service resources. In the light of the story in today's The Guardian that the Secretary of

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State for Health has admitted that she does not know how much GP fundholding is costing the health service budget, how can the Government proceed on this basis?

Mr. Malone: The hon. Lady gives a partial account of an inaccurate story, which I read with some interest this morning. Of course we seek to identify the cost of providing services, and I shall return to that later, but I now wish to deal with the point about management costs that was raised earlier.

Mr. Jenkin: Will my hon. Friend give way?

Mr. Malone: I must make some progress, as I do not want to occupy too much of the House's time. I wish to deal specifically with a number of the points that have been made.

New money is being spent in London, and much is happening. The development of new day centres is important, because it changes the pattern of need, moves us away from the idea that care must always be in the hospital, and underpins the fact that there should be no fiat from the Department or from me as a Minister.

I was flattered to gain the feeling from the House that it would be better to get rid of the NHS so that hon. Members could ask me what to do. We must change the perception of where we are in the health service, and understand that reforms are driven by patients through primary care. Through the contracting and purchaser-provider relationship, patients now determine the pattern of care.

Mr. Jeremy Corbyn (Islington, North): Will the Minister give way?

Mr. Malone: If the hon. Gentleman does not mind, I shall not, as I wish to deal with a number of hon. Members' points.

Let me turn to the important question of consultation. In the next few weeks and months, there will be public consultation on changes in north- east London, and in the north central sector early in the new year. I expect to hear proposals from west London as soon as possible.

My right hon. Friend the Member for Chelsea (Mr. Scott) mentioned the Royal Brompton hospital. I listened to what he said and--although this may not reassure him, it will at least show the attention that we have paid to these matters--I have a visit scheduled to that hospital. I shall consider the proposals to which he referred, which will be borne very much in mind.

The south-east London commissioning agency expects to consult on its proposal for change from the middle of November. As the hon. Member for Southwark and Bermondsey said, we are proceeding on the Guy's/St Thomas's proposal. I hope that consultation will get under way quickly and that, once it is concluded, we shall be able to achieve a stable result as quickly as we possibly can.

My right hon. Friend the Member for City of London and Westminster, South mentioned Bart's. The Royal London hospital trust has embarked on an important plan, which we believe will improve hospital services for all people in that part of London. I visited Whitechapel hospital yesterday, where I saw what is being done. I say to hon. Members who have mentioned its future that £8 million of refurbishment expenses were authorised yesterday. The hospital will now redevelop four wards,

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improve the accident and emergency unit and put in place an emergency ward next to the casualty department. Those are all extremely important improvements.

We recognise that change is difficult, but we need strong and determined leadership. As my right hon. Friend the Member for City of London and Westminster, South clearly recognised, we need to proceed: we do not need delay, uncertainty and continuing paralysis. When I talked to the clinicians yesterday--not only those from the Whitechapel hospital but from Bart's--the message that came through loud and clear was that no one should stand in the way of change, some of which they may not like but which they regard as necessary if services are to be put on a stable footing and if the teams of clinical excellence are to be kept together.

Mr. Corbyn: While the Minister is talking about nurse-managed beds, does he realise that, in many parts of inner London, people leaving acute beds, who are elderly, often have no one at home to support them, and only very limited social services support? Is he prepared to listen to proposals to convert the Royal Northern hospital in the Holloway road into a nurse- managed bed centre for people leaving acute wards, instead of selling the building?

Mr. Malone: I am glad that the hon. Gentleman has asked me to listen, and not to decide as others have done. I do not wish to palm him off with the motherhood answer--"Of course we will listen". We do listen, but we do more. I like to inform myself of precisely what is happening. As I go around London, I ask precisely what is being done about the community care packages that are being put

together--especially the primary care packages, with which I shall deal shortly and which cover hospital-at-home services and ensure that the boundaries that used to exist between primary carers of all types are being broken down.

I concede that the hon. Gentleman has a point, but it is being dealt with. He will be aware that substantial improvements are being made. I now revert to the motherhood answer, and can tell him that I will examine seriously any suggestion that he cares to make. I deal again with the point raised by my right hon. Friend the Member for City of London and Westminster, South. I should like to read a letter that we received from a professor of medicine at Bart's, which states:

"We are in no doubt that making no change in the current environment would result in severe damage to the working of all three institutions. We are confident that the proposed plan, if approved after consultation, and if appropriately funded, for the development of a modern hospital on a single site at Whitechapel over the coming years, will provide all the stability and facilities required to look after our local population and provide outstanding specialist services for others from far away."

That letter highlights the fact that there are opinions among the professionals who work at the institutions involved which are much at variance with what is often perceived to be the public view.

Mr. Brooke: The hazard in quoting individual documents and individual observations is ascertaining whether they are genuinely representative of the institutions from which they come. Some people might say that the particular letter cited by my hon. Friend is not representative of the institution from which it comes.

Mr. Malone: I concede that there are many opinions, and that they must all be taken into account. My point is

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that some people believe that restructuring is necessary. I hope that we can draw up a co-ordinated plan in order to ensure certainty and end any further delay.

My right hon. Friend asked me specifically about the services that would be moved, and whether there would be sufficient investment to provide replacement facilities. Such matters are informed not only by the decisions taken by the Department but by other matters. It is, for example, rather premature at this stage in the public expenditure survey to give details of any decisions. I know that my right hon. Friend will understand that well enough.

I give this undertaking to the House: the Government are committed to making resources available to fund rationalisation wherever necessary. It was brought home to me vigorously yesterday that it is important to convince clinicians who were being asked to move that the new facilities would be on all fours with the facilities that they were leaving. That would certainly be an objective. For the reasons that I have stated, I cannot give my right hon. Friend an undertaking as such on that point, but I hope that he understands that that is the objective, and that our deliberations are cast in that way and in the light of all that.

We are rightly proud of the history of much of London's medicine, not least of all science and research, and I now turn to that point. Unless we adapt to the very different reality that we face now, there is a great danger of condemning London's research to the second division instead of it being in the premier league, where more people suggest it should belong. The risk of inaction now is that London's teaching and research institutions would lose their range and flexibility and would become marginalised. Doing nothing in that sense is not an option.

Research thrives where expertise is concentrated--the hon. Member for Southwark and Bermondsey made that point. It thrives where different disciplines can form a critical mass of teaching, research and clinical practice, where biochemists can work side by side with cancer specialists. If we allow London's research to remain fragmented, the slide that is now perceptible will simply continue. Planned changes will address the problem.

All the undergraduate medical schools proposed for merger are now committed to merge, and are developing their plans. Progress in linking postgraduate medical schools to multi-faculty colleges has been faster even than we had hoped. Funding is available to do all this. The Higher Education Funding Council for England has announced a £50 million fund for capital projects between 1995 and 1997, and has invited bids from merger groups. The Department of Health has supported with funds some of the developments that have been triggered by the service changes, and I welcome all that. It is important to make those who write, along with the bishops and actresses from abroad who were, perhaps, better acquainted with all the institutions some decades ago, understand that, if the institutions are to survive, playing in the premier league, change is now essential, and we must now move on.

I turn now to some of the points raised in the debate. My right hon. Friend the Member for Chelsea not only welcomed the success of the Brompton and its record of excellence in delivering specialist clinical services and supporting high-quality medical research, but talked much

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about the pattern of provision that he wanted to see in the area that he represents. Of course we shall listen to all he has said, and I can promise him this.

My right hon. Friend asked, as many other hon. Members have done, that uncertainty be kept to a minimum. I can promise him that, once consultation processes have been gone through and looked at thoroughly, within the context of that thoroughness Ministers will, of course, act promptly to ensure that there is the least possible delay. My right hon. Friend asked me to reassure him on that point, and I am extremely happy to give him that reassurance.

The hon. Member for Leyton made a number of points, referring specifically to improvements in the family doctor and community health services throughout the capital, which he said were not there. I tell him that these matters are proceeding.

Primary care is one of the first things that I looked at on becoming a Minister late in July. I take the improvement of primary health care in London extremely seriously. I was amazed to discover the state it was in when I came to office, and I was disappointed that a number of obstacles were still clearly in the way, driven by the health service before it was reformed. Only now, through the actions of clinicians, has the health service been able to make improvements. Anybody going round London now, who looks at the surgeries of the future rather than having to examine those of the past, will know precisely what I mean.

Ms Tessa Jowell (Dulwich): I am sure that the House shares the Minister's view that improvements in primary care are urgently needed and are a precondition for any subsequent changes. Does he accept, however, the point already made, that improvements in the quality of primary care do not necessarily lead to a reduction in the demand for secondary care? Indeed, the evidence points in quite the opposite direction. Does he accept that point?

Mr. Malone: No, I do not accept that point in the way that the hon. Lady puts it because, in the primary sector, quite a lot of care is now provided which used to be provided in the acute sector, in the ways that I have already outlined. I do not think that there is any logical connection at all in suggesting that improving primary care will either automatically increase in a dramatic way the calls on the acute sector.

Much of what is being done in the reshaping of primary care is taking care away from the acute sector and into the community where it properly belongs, may I say, and in an excellent way. I have seen a number of examples of how the funding made through the Government, and particularly through local health services, in primary health care in London has worked.

As I was saying, I was in the constituency recently of the hon. Member for Southwark and Bermondsey in the rather curious location of a surgery by the name of The Dun Cow. It was an old pub. There was a happy photograph on the wall of the hon. Gentleman opening the surgery--at that stage not with balloons in his hand,

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but with a pint of beer. I did not know that he tippled to that extent. I shall have to have a word with the chief medical officer about that.

Ms Dawn Primarolo (Bristol, South): It is in moderation only.

Mr. Malone: I may need to take the advice of the hon. Lady on that. But there it was--a £400,000 development. I was keen to look not simply at the new premises, but at the old as well.

Frankly, such premises are still all too common in London. When I look at new premises, I always insist on asking the question, "Where have you come from?" Often, they have come from facilities which are outdated, where proper medical practice cannot take place. It is important that many of the facilities which can now be brought to bear in primary care, even through pressure of size of accommodation, cannot be sorted out. How does one, in what is often a single room with partitions, bring in either a physiotherapist, a practice nurse and all of the things that primary care packages, especially when they are organised by GP fundholders, are able to provide? I have also been extremely impressed by a number of other developments. The point that I wish to make bears directly on the issue of accident and emergency departments. I do not want to go through a list of yesses, noes or perhapses and all the representations that have been made in the debate, but there are examples in London of accident and emergency departments being successfully replaced by minor injuries units.

The first one that I visited was at the St. Charles hospital. It is a first -class unit run by a combination of nurses and general practitioners in alliance with consultants from the local general hospital. It was asked earlier whether such units were effective or not. Where it is agreed that protocols can be sorted out between the nurse who runs the unit and the local consultants, they are enormously successful. They can deliver health care in an excellent way. The unit at St. Charles was putting through 15,000 patients a year.

I hope that all our debates on the future of accident and emergency units will be informed by the fact that perhaps, there too, medicine has moved on; needs have changed. It is rather important to recognise that, and to look not only at the old institutions.

The hon. Member for Feltham and Heston (Mr. Keen) made a specific point about a plan in a local hospital in his constituency. I shall certainly consider all that when it eventually comes to Ministers. I cannot give him any undertaking to do more than that, but as that is the undertaking he sought, I hope that, when he hears of it, he will take it in the good will in which it is given.

The hon. Gentleman also raised an important point, on which the House reflected, about trust board membership. I am rather looking forward to the opportunity that the Opposition have given us to debate the point at some length next Tuesday, because up and down the land many people-- professionals--are doing what is almost voluntary work for the health service. It is conducted in a first-class way, and I believe that they serve the service well.

I do not share the view of Opposition Members, who think that that is not a proper way to run affairs. I think that it is an excellent way in which to run those trusts. They make a marvellous contribution. The hon. Member

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