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Column 32clinical teaching and research. I shall be announcing more money for primary care. I shall tell the House of important new developments around some of the hospitals and medical colleges in London and important changes taking us nearer to the heart of our vision of four world-class hospital complexes clustered around multi-faculty universities and colleges.
I congratulate the right hon. Member for Derby, South (Mrs. Beckett) on being here to open the debate. The last time Labour Front-Bench Members chose to debate health in London, their health spokesman did not even turn up. Instead, their transport spokesman came along, mouthed a few sound bites in advance of impending local elections and sat down. He said nothing about Labour policy. That showed the real face of the Labour party: it is interested not in serious health issues but only in party politics and partisan advantage.
I give credit to the right hon. Member for Derby, South. She suffered widespread criticism of her Trappist approach to Labour health policy. With some justice, The Lancet recently asked: "What would a Labour government do with the NHS?"
With some justice, it gave the answer:
"It's no use asking the Party's spokeswoman on health; she refuses to say".
However, the right hon. Lady has now produced a plank of policy. Unfortunately, it is the wrong policy, but we cannot have everything. She wants a moratorium on bed closures in London. She wants, as her motion states,
"a fresh and thorough review".
There have been about 20 fresh and thorough reviews in the past 80 years, and they have all said the same thing: we need movement and improvement, not a moratorium. London needs action and change, not yet another review.
Labour Members have cut themselves off from what has to be done. They have ignored even the advice of The Guardian , which stated: "A party preparing for Government should resist the easy option--opposing all hospital closures--and concentrate on filling out its own plans."
Rarely can a party have so wallowed in the irresponsibility of opposition. Labour Members' dithering in opposition shows why Labour would be such a disaster in government.
I should say at the outset that I cannot comment in detail on the proposals around St. Bart's, the Royal London, or Guy's-St. Thomas's. They are or have been the subject of statutory public consultation and as Secretary of State I am in a quasi-judicial position in relation to the proposals which are likely to come to Ministers for final decision.
Mr. Brian Sedgemore (Hackney, South and Shoreditch): The consultation period on whether Bart's is to close ends tomorrow. Yet in yesterday's edition of The Sunday Telegraph there was a quotation from a letter from the Secretary of State for Employment saying that the decision to close Bart's had not been taken lightly by the Prime Minister and by the Government. What is the point of consultation when decisions have been taken before 6 February and consultation is continuing until 21 February?
Column 33there should have been any misunderstanding at all. I am sure that the hon. Gentleman and his constituents, and my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke), will be extremely pleased to hear that.
The hon. Gentleman will be aware that on the previous matter there was a great effort to take the issue to judicial review. That challenge was totally and utterly rebutted. In all matters, Ministers have behaved with absolute propriety and will take forward the consultation in the proper way. I am delighted to make that absolutely clear.
These are serious matters affecting not only London and Londoners but people throughout the country. I should like to set out again the underlying issues facing those and all the great hospitals in London. They are the same issues which face the south-east and the rest of the country. The issues are linked: what we do in London affects what can be done outside London. The London health service is part of a national health service.
The service in London faces many difficult challenges. One of the reasons why we began the process with Tomlinson was precisely to address those problems head-on. To duck out now would blight the capital's health service for at least a generation. The Labour party's shoddy analysis of London's needs and problems will not do. The fundamental issues, none of which the right hon. Member for Derby, South addressed, result from changes in where people live, changes in how they choose to be cared for, and the need to adapt to the evolving potential of modern medicine.
Within a six-mile radius of this place there are about 22 major acute hospitals. That cannot be said of any other part of the country. That concentration of hospitals grew up mainly in the previous century to meet national rather than specifically London needs, let alone the day-to-day needs of local communities. The population has moved away. London's population has fallen dramatically by about 1.3 million in the past three decades. People who used to come to inner London hospitals from all over the south-east and beyond are now turning to their own hospitals for care.
Lady Olga Maitland: My right hon. Friend refers to the reluctance of patients to come to London. Is she aware that patients in my constituency in Sutton can now go to the St. Helier's national health trust hospital, which provides all the services they need?
Mrs. Bottomley: A generation ago, people travelled from the home counties to the London hospitals, but there has been a massive development of services throughout the home counties. Patients and GPs rightly say that they would rather have treatment close to home than travel to London. That is precisely what is causing great difficulties for the London hospitals, which have fixed overheads.
Mr. John Austin-Walker (Woolwich): Does that square with the Secretary of State's decision to transfer further into London the regional neurosciences units and the cardiothoracic units based at the Brook hospital in Greenwich, which serve the Kent area?
Mrs. Bottomley: I shall be emphasising at some length later in my speech the crucial importance of academic excellence and research. London has been a capital city for medical research and teaching, and there is duplication
Column 34and fragmentation of centres. If we wish to be a world capital for medicine in the next century, we must concentrate on centres of excellence.
We undertook an unprecedented review of the specialty services, in which about 200 clinicians were involved. The prime position given to the Institute of Psychiatry and the campus at Denmark Hill, and the contribution which could be made to international research and teaching by the integration of the neurosciences centre from the Brook hospital were decisive factors in our supporting the recommendation. It is precisely that commitment to excellence that has driven the framework within which the changes have been seen.
Mr. Hugh Dykes (Harrow, East): I am sorry that I was late for my right hon. Friend's opening remarks. She rightly referred to the growing importance of a comprehensive range of services in outer London and in the home counties. Does she agree that it is vital to keep open--in all and in part--the services of Edgware general hospital in the future?
Mrs. Bottomley: My hon. Friend--like almost every constituency Member of Parliament--has a great affection for his local hospital, the way in which it has evolved over the years and the service that it provides for the local community. The dilemma that we face--which any responsible Government would face--is that report after report has argued that if we want clinical excellence we must look towards the consolidation of services. For example, at the Royal London we can have a 24-hour consultant -led accident and emergency department. A couple of weeks ago, a major report from the clinical standards advisory group argued again about the quality that we should be looking for in an accident and emergency department. We can deliver that quality, commitment and back-up in terms of staff only if units come together. A balanced judgment must be taken on the pace at which we move towards those centres.
Another example is cancer services. The Chief Medical Officer's report on cancer services argues for a concentration of centres with a relevant critical mass, which always leads to difficult decisions for individual Members of Parliament.
I say openly to the House that if we want to have the quality of services advanced by the royal colleges and by virtually every expert report, we must see how we can address the issue of hon. Members' great affection for their local hospitals which cannot provide the critical mass, the sub- specialties and the costly equipment that we need for state of the art services.
Mr. Dykes: On a point of order, Madam Speaker. In view of the unsatisfactory nature of that reply, I beg leave to give notice that, with your permission, I shall seek to raise the matter on the Adjournment.
Madam Speaker: I have noted what the hon. Gentleman has said, but as the motion is not a substantive one he should not have interrupted at this stage. He must seek an Adjournment debate and take his chance.
Column 35when looking at the interface between a series of expert reports and the understandable and strong views of constituency Members of Parliament.
Several hon. Members rose --
Mrs. Bottomley: I should make headway. The point is well made. The constituency points made by my hon. Friend are subject to consideration. Decisions have not been made. I was using the example to make a more general point.
Not only do we have hospitals around London. As my hon. Friend the Member for Sutton and Cheam (Lady Olga Maitland) said when she gave an example from her constituency, some patients who are treated in London would prefer to be treated closer to home. An example is the new cardiac unit being built in Plymouth to treat, among others, patients who currently come 250 miles to the Royal Hospitals trust. A new £5 million cardiothoracic centre is being established in Brighton. There are two major new oncology centres, in Maidstone and, as my own constituents know well--
That is the modern health service taking root. History has left a proliferation of small specialist units within a few miles of each other in central London. Before the hon. Member for Workington (Mr. Campbell- Savours) gets too carried away, he will want to know that in my constituency I have faced precisely the changes that I have described in relation to my hon. Friend the Member for Harrow, East. My own hospitals are becoming community hospitals because we have a concentration of speciality services outside my constituency, in Guildford. I hope that the hon. Gentleman understands that. Those small units, often within a few miles of each other, are run by skilled clinicians. In these days of modern medicine and high technology, it cannot make sense for the speciality reviews to find 10 radiotherapy units, 13 cardiac surgery departments and 11 renal dialysis centres all in such close proximity. The simple fact is that it is impossible to sustain the highest quality care in so many fragmented centres. The talent and expertise of the clinicians, and the money available to purchase equipment, is too thinly spread. As I have made clear, the number of patients referred to London for specialist treatment will fall. As it does, it will become ever more difficult to maintain the quality of services in each centre. The royal college training accreditation is in jeopardy in neurosciences and other specialities at Bart's because the number of patients that it treats is now below the clinically recommended levels. For example--this, again, is an issue for my hon. Friend the Member for Harrow, East (Mr. Dykes)--Professor Sir Norman Browse, the president of the Royal College of Surgeons, has said:
"To maintain and improve professional standards, we have to amalgamate the remaining in-patient beds so that they achieve the critical mass necessary to provide the experience needed to train and educate junior doctors and maintain the consultants' expertise."
Column 36Time and again, expert and independent speciality reviews have argued that for better patient care we must have specialist services concentrated in fewer, larger centres, so as to make better use of finite resources and dedicated staff.
Modern clinical equipment is expensive. A computerised tomography scanner can cost £500,000. A magnetic resonance imager can cost £1.5 million. By clustering hospitals, we can ensure the best use of these medical miracles, which were not even conceived when the NHS began in 1948, let alone when most of London's hospitals were constructed in the last century.
We can make better use of our doctors, with their highly specialised and scarce skills. We are committed to reducing junior doctors' hours. My hon. Friend the Minister is meeting them this week to discuss the issue further. Smaller units needing 24-hour cover require junior doctors to be on site all the time. With fewer larger centres, the load can be spread. We can achieve the ambition both of the Government and doctors to improve the quality of life for medical professionals.
There is another reason why we need fewer, better centres. Fragmenting services across so many sites makes it much more difficult to manage beds. We frequently hear about the pressure on beds for emergency admissions and I do not discount the problem. A recent comprehensive study in London, carried out by the inner London health authorities, dealt with that important issue and I commend it to the House. Copies are easily available in the Library and, I believe, in the Vote Office.
The report states:
"Larger hospitals and those with larger pools of beds were found to be better able to manage variations in demand for admission. Those with a lower proportion of emergency admissions could operate at higher occupancy levels."
The report concludes:
"Better clinical and management systems than in the past need to be in place if such problems are to be handled without detriment to quality of care or the planned admission of non-urgent patients." In a significant passage, it states:
"It was thought that extra acute beds would not solve those problems in a cost-effective way. They are better addressed by the management of admissions and discharges in collaboration with all the parties involved."
The Government have set out the strategic direction for the health service in London, which that important report endorses.
Mr. Peter Shore (Bethnal Green and Stepney): On the important question of concentration of facilities in one spot, obviously there is an argument for larger and fewer units and we are familiar with it--it applies to many things other than the health service or hospital services--but there are disbenefits and additional costs from highly concentrated organisations.
The London hospital is to be concentrated on the Whitechapel site, with the closure of the London Chest hospital, part of Bart's and the Queen Elizabeth hospital. A huge and costly investment programme will be necessary on the Whitechapel site to provide facilities which one hopes will be similar and equal to those to be closed. Is there any guarantee that the money will be made available within the time scale involved?
Column 37document, he will know that, out of something like a £95 million cost for the status quo, much of the capital cost will be used to refurbish the existing facilities. The document suggests that there will be revenue savings of £22 million a year as a result of concentration on one site.
The right hon. Gentleman will be aware that academics and researchers feel strongly about the great opportunity to bring together research teams; with a larger group, they can have sub-specialties and all the opportunities of mixing disciplines. Academics, with whom I spend an enormous amount of time, are concerned that if we allow the fragmentation of the small centres to continue it will be almost impossible to build up the substantial clinical and research teams with which they hope to pioneer innovations.
Mr. Forman: I am mindful of my right hon. Friend's argument about the benefits for academics of an inter-disciplinary approach in large clusters of hospitals, and it obviously makes sense. But is she aware of another argument, which tends to point the other way--the possibility of diseconomies of scale on the managerial side if the management of those vast enterprises are expected to manage something many times larger than the units that they were managing?
Mrs. Bottomley: I accept my hon. Friend's argument, but the hospitals that we are discussing are relatively modest in size compared, for example, with some of the most internationally famous hospitals in the United States.
I regard Boston as a competitor with London in terms of the prime position in medical research and teaching. It was interesting for me to meet the professor in charge of Massachusetts university hospital recently as he was amalgamating a 1,000-bed hospital and an 800-bed hospital. The changes that we are making in London are being made in Boston, Sydney, Paris and virtually every capital city in the world. Those changes matter so much partly because Londoners deserve a better health service. As the right hon. Member for Bethnal Green and Stepney (Mr. Shore) may know, my first job was in Bethnal Green, so I know only too well how inadequate and paltry the community and family doctor services were for people in that area. However, I am also strongly committed to our international position and centres of excellence. It is no coincidence that our university hospitals of Oxford and Cambridge, in areas where there is no fragmentation or duplication, find things much easier than some London centres precisely because those are so numerous.
It would be wrong to delay matters, have a moratorium, and abandon the process of change because that would put everyone in limbo and a state of uncertainty. People in London want to know what the future holds and to build for the next century.
Sir John Gorst (Hendon, North): Will my right hon. Friend help me by reconciling her logic and information with the illogical feelings of my constituents, who are unanimously against her proposals? Have I any alternative but to represent their views in the Lobby, contrary to how my right hon. Friend would wish?
Mrs. Bottomley: I repeat what I said to another hon. Friend: a balance must be struck between the move towards clinical excellence, the concentration of services, better services, the issue of junior doctors' hours, and the pace at which change can be achieved. Issues concerning
Column 38my hon. Friend's hospital are being carefully addressed. I totally accept that every hon. Member must balance local wishes, which are nearly always to avoid change--the populism that we have seen from the Opposition today--and a more principled approach which believes that if we want clinical excellence for the future we must face and take difficult decisions.
We need to invest in the acute sector and more must be done to improve infrastructure in London. We are backing our commitment with a substantial amount of cash: £28 million for redevelopment of the Lewisham hospital; nearly £20 million to develop the Homerton as a full district general hospital serving the people of Hackney; nearly £15 million for the London ambulance service--
Mrs. Bottomley: I heard the hon. Gentleman's intervention in the speech of the right hon. Member for Derby, South and I shall consider it carefully. I greatly appreciated our lengthy and informative discussion on the subject earlier in the year.
We are spending more than £8 million to upgrade and expand the accident and emergency department at King's--
We are spending £3.2 million on the St. Thomas's accident and emergency department; £2 million for the Whittington; and nearly £2 million at the Royal London. [Interruption.] Opposition Members do not want to hear that list of investments and would rather drown it out, so substantial and significant is our record of investment in the London health service.
The list goes on and on, but the key issue is that it is investment in the future, not in the past, and it is close to where people live. We should not continue to sustain the current revenue cost of £70 million a year in duplication and fragmentation of an outdated pattern of hospital care. To do so would be unfair to the taxpayer, to other parts of the south-east and the rest of the country and to London when money should be targeted on basic health services in the community, which are so badly needed.
We have come to terms with the paradox that clinical developments point to a need for fewer acute beds. It is a paradox, and I understand hon. Members' concerns, but we see the development of day surgery, minimally invasive surgery, new drugs and other medical advances. All of those mean that we can treat more patients in fewer acute beds.
Because of those developments, the number of beds has been falling in the UK and elsewhere for the past 30 years. But fewer beds do not mean fewer services. There has been a massive expansion in the number of patients treated, reductions in waiting times and a transformation
Column 39in the range and sophistication of treatment available. In the past year, the number of people waiting more than a year for treatment in the Thames regions has fallen by 7 per cent. In a five- year period from 1988, the number of hip replacement operations increased by 2, 500. During the same time, there was a fourfold increase in the number of liver transplants. The Labour party should know that it is simplistic just to look at the number of acute beds. We must consider how they are used and what that tells us about the balance between acute and non-acute beds and services generally.
The inner London health authorities' report concluded that the use of acute hospital beds is significantly above the national average. But there is no evidence to suggest that, on average, Londoners need to go into hospital more than people living elsewhere in the country. What the figures reveal is that the wrong beds are being used in the wrong way. Patients-- particularly elderly patients--are being kept in hospital longer than they need be when they could better be discharged to proper care outside hospital, which is better for patients and for the NHS. For some, that will mean a nursing home. Evidence shows that, since our community care reforms, the number of nursing home places in London has begun to rise--200 more this year, but 1,800 more in the pipeline. That is a substantial increase in the number of nursing places for older people.
Local authorities have been well funded to meet their new community care responsibilities. This year, the London boroughs have received a total of £850 million for community care--more than one fifth more than in 1993 -94. The funds available will rise by a further £95 million for 1995- 96. The London boroughs are well placed to support a continued growth in nursing and residential facilities outside hospital. We look to them to discharge that stewardship in a responsible manner. As Professor Jarman has pointed out, we need more "low-tech" beds, as he calls them. It is because of the Government's reforms and the money that we have put back into them that the expansion in services is at last becoming a reality.
The right hon. Member for Derby, South referred to primary care. Sadly, primary care in London has lagged behind other parts of the country, but it would be quite wrong not to draw her attention to the very substantial improvements that have been made since the Acheson report. Of the 31 main recommendations of the report in 1981, 26 were implemented within 10 years. Between 1978-91, the number of general practitioners in London increased by a further 310 from 3,523 to 3, 833. Many other recommendations were implemented: the retirement age for GPs; higher payments in underprivileged areas; standards for the reimbursement of rent of surgeries; screening for people over 75; and the co-ordination, by community health experts, of district health authority services for children. The right hon. Lady would be quite wrong to fail to recognise the dramatic changes that have been under way, but there is clearly a need to do even more.
Over the past two years, we have already invested an additional £125 million in primary care, which is creating and supporting more than 1,000 projects in London's areas of greatest need. A transformation is under way. There are more than three times the number of practice nurses as five years ago. The GP contract, introduced in
Column 40the face of bitter opposition from the Labour party, has brought an increase in child immunisation and cancer screening, of which my hon. Friends are so proud. Above all, the GP contract brought in extra payments for family doctors working in deprived areas. What hypocrisy it is for the Labour party to lecture us about poverty and ill health when it opposed that measure in the House.
Despite those achievements, however, there is more to be done. I am pleased to be able to announce that we shall be investing a further £85 million in primary care initiatives in London's most needy areas in 1995- 96. That is a substantial sum. I know that my hon. Friends who represent areas outside London want it to be wisely and well spent, but it will enable us to implement our key objectives--to improve GP practices and other primary care premises; to increase the range of services that GPs can offer their patients; and to assist the development of health teams working in the community. It will include an investment of £20 million over two years in a new education programme for London GPs.
Mrs. Bottomley: I do not intend to give way again. I have already given way many times, and I know that my hon. Friends are keen to speak. I am normally rebuked for giving way too much, so I hope that the House will bear with me.
Mr. Corbyn: On a point of order, Mr. Deputy Speaker. We rarely engage in debates on London's health. If the Secretary of State is not prepared to give way, how on earth can we use our one opportunity to question her directly about matters of deep concern to all hon. Members?
Mr. Deputy Speaker (Mr. Geoffrey Lofthouse): I said from the Chair the other day that I had long waited to hear a genuine point of order. I also said that it was very unlikely that I would do so in the near future, but that I lived in hope. I am not very satisfied with what I have heard today.
Mrs. Bottomley: I am between the devil and the deep blue sea, Mr. Deputy Speaker. I should make it clear that I regard the Chair as the deep blue sea and the Opposition--otherwise. Madam Speaker often severely rebukes Front Benchers for speaking at great length. I realise that I have already spoken for longer than the right hon. Member for Derby, South, although I think that I have given way more times than she did, but we shall consult the record tomorrow. The issues involved are enormously important. We want to introduce improved training programmes to attract and retain high quality family doctors, and to improve opportunities for GPs to maintain high standards where they are needed most. We are also considering further steps to help, in particular, smaller practices to recruit and retain practitioners and assistants. We want more and better GPs, providing better services; we want in London family doctor facilities and community teams of the range and quality that are already common elsewhere. We want more of the fundholders who have been the pioneers of change in primary care. I am pleased to say that we expect London and the south-east to match the rest of the country by April, with some 40 per cent. of its population covered by fundholders.
Column 41I also welcome the prospect of GPs forming groups to purchase services for their patients, and the news that Professor Jarman and others are to join the central London multi-fund.
We are targeting people with specific needs--the elderly, the homeless and people with mental health problems. In the current year, £10 million of additional money is being invested in better services for the mentally ill in London. I can also announce that at least the same amount will be available again in the coming year for the special needs of people with mental illnesses. A vast range of programmes is now in place around the capital to improve care in the community for mentally ill people.
There are schemes such as that run by the Hackney Sanctuary, which provides crisis support to help avoid the admission of patients to acute hospital beds, and there is a new residential scheme in Camden and Islington. There are other schemes in Hounslow, Lambeth, Hammersmith, Greenwich, Haringey and Croydon; throughout London there has been rapid investment in practical schemes to help those with mental illness cope in the community. Time and again, Opposition Members re-emphasise their commitment to the principles of care in the community; I ask them to recognise all that is being achieved, and to acknowledge that more will be done because of the extra money that the Government are committing.
I feel that, as we are discussing important and serious issues, I should set out what is happening, what has been achieved and the issues that remain to be tackled. My hon. Friend the Member for Carshalton and Wallington (Mr. Forman) referred to the importance of education and research. Those are fundamental to the reputation of London as a world leader in medical teaching and research. Bringing the different specialist centres together in the way that I have already described is difficult, but it is a vital part of securing the long-term objective.
The synergies which consolidation brings will help research thrive. Formal academic integration of pre-clinical medical education with the basic science faculties of the university of London will enhance the range of options for students, researchers and clinicians. [Interruption.] It is noteworthy that the Opposition greet with mirth and merriment issues that for many years have concerned Lord Flowers, Lord Annan and the vice- chancellor of London university. People feel deeply about these issues and they should be given proper priority as the changes take place.
We are working towards our vision which is based on four world-class hospital complexes clustered around four world-class colleges. The multi- faculty colleges will provide the engine room of basic science. This will be carried through in their associated medical schools and hospitals into clinical science and clinical research. It will allow the benefits, for example, of new advances in molecular biology and genetics--advances pioneered in this country--to have practical results in the care of patients.
We are making strong progress. All undergraduate medical schools proposed for merger are now committed to merge and are making plans to bring this about. The Institute of Psychiatry, associated with the Maudsley hospital, has entered into a formal association with King's college. A private Bill to enable the merger of King's college with the united medical and dental school of Guy's and St. Thomas's is currently passing through another place.
Column 42The Maudsley is the world's pre-eminent research institution of its type. People are already coming from all over the world to work there because of the great opportunities that it offers. Imperial college recently announced agreement by the Charing Cross and Westminster medical schools, the National Heart and Lung Institute and the Royal Postgraduate Medical School to merge with Imperial and the St. Mary's medical school to form a new Imperial medical school. The new school will make a significant contribution to both undergraduate and postgraduate education and to research. It will contain several teams of the highest international standing. These proposals will forge a brilliant alliance between some of our top clinical researchers and Imperial's scientific and engineering excellence.
The merged college will be focused on a new basic and life sciences building to be built at Imperial's Kensington site. The financial case is still being examined by the Higher Education Funding Council. However, I can announce to the House that I am prepared in principle to commit a substantial capital contribution to the scheme. As a result of this work, and the money with which the Government are prepared to back it, the new school should be admitting its first students in the autumn of 1998.
Our policies are also working to underpin the international reputation and excellence of University college hospital. It is making good progress in its association with the institutions based in Queen's square and has recently completed a financial case for the development of the Gower street site. This proposal has strong support from the academic and clinical community. I hope that formal consultation on the resulting service changes will begin before Easter.
I also commend to the House the private Bill which would enable the merger of Queen Mary Westfield college with Bart's and the London hospital medical colleges. These multi-faculty colleges with their clusters of hospitals in London will be ideally placed to take forward the highest calibre medical education and research. The critical mass of expertise within each centre will allow the widespread dissemination of best clinical practice.
Mr. Jim Dowd (Lewisham, West): On a point of order, Mr. Deputy Speaker. The Secretary of State has been speaking for 40 minutes. I accept that she has taken a number of interventions, but in the spirit of Jopling- -
Mrs. Bottomley: I am coming to the end of my speech, but it would be wrong for the House not to be aware of how much is happening in terms of the investment in primary care and mental health services and how vital is the consolidation of medical research and teaching if we are to take pride in our national health service for the century ahead.
The Government will not shy away from what must be done. We utterly reject the Opposition's vacillation and evasion. We will have no truck with their moratoriums, their counsels of delay. We reject their plans for a health service run by councillors, which would inflict on our hospitals the same unholy alliance of bureaucrats and