|Previous Section||Home Page|
Column 43councillors as we saw in the Greater London council, which left thousands of Londoners isolated in inner London despair. As The Economist said:
"The choice, after all, lies between preserving Victorian glories and providing better health care for Londoners."
London deserves a health service that is fit for the 21st century. Much hard-fought ground has been won, momentum has been generated and much has been achieved. We wish to carry the services forward, accept the change and bring an end to uncertainty in the interests of medical research, staff and patients in London and throughout the country.
Ms Tessa Jowell (Dulwich): I tried about half a dozen times during the Secretary of State's speech to ask questions, but I regret that she did not give me or a number of my hon. Friends the opportunity to intervene.
On Saturday night, I visited five accident and emergency departments; it is in those departments that pressures are most felt, because of lack of beds. I visited King's College hospital, which is used by most of my constituents, Homerton hospital in Hackney, North Middlesex hospital, Chase Farm and the Whittington, which is my local hospital. Each one except the Whittington was having what was described as its quietest night for weeks. As one sister put it, "Usually by now patients and trolleys are everywhere, coming out of the woodwork. It is chaos."
Each hospital had free beds. For example, the Homerton had 10 beds when I arrived but during the 45 minutes of my visit, five were filled. I was told by one of the sisters, "On a night like this, we do a little better than just cope." That is what is happening on an easy night in London's accident and emergency departments. In every hospital, the staff thought that they were having an easy time if they had any free beds at all. In each hospital, the circumstances of the past 12 weeks were described as barely tolerable for staff or patients.
On 24 January, at King's College hospital, there were 19 trolleys, each with a patient waiting for a bed to become free. On 6 February, also at King's, there were 15 patients waiting on trolleys. At the Homerton two weeks ago, 26 people could not be found beds and at the Whittington the weekend before last, an extra 37 beds had to be put up. During my visit, the staff thought that they were having a quiet night because the pressure was off, but only one of the hospitals had an occupancy of less than 98 per cent. The inner London chief executives' report, to which the Secretary of State referred, accepts that that is too high and that hospitals should aim for a bed occupancy of 85 per cent. if they are to deal with the fluctuations of demand. Ministers believe that better bed management will be the solution to the bed crisis.
One of the reports that accompanied the inner London chief executives' report made plain what passes at the moment for a bed management strategy . The report states:
"In most cases action is taken as occupancy approaches the hospital's `danger' level".
It refers to
"the early discharge of patients by consultant led ward rounds...Clearance ward rounds were a common feature of hospital life . . . The cancellation of elective admissions or the restriction of elected work to urgent cases only . . . Use of the EBS system"
Column 44that is, the emergency bed system
"to restrict the hospital to its catchment area or to medically refereed cases".
I have the latest figures for the emergency bed system, which show a 100 per cent. increase in the number of patients admitted as a result of being medically refereed for the month of January-- the intolerably pressurised month referred to by so many of those to whom I spoke on Saturday.
The report continues:
"Treat and transfer arrangements were not a common response. Experience suggested that in times of bed shortages other hospitals were generally unable to provide cover."
The report says that mixed-sex wards, and even mixed-sex bays, are now common. It points out that the transfer of patients between wards and, in some cases, between sites make compliance with the patients charter named nurse standard difficult. It also says:
"Putting up extra beds and the opening of closed wards and bays at very short notice were reported by most inner London Trusts" There was also the
"Use of day or 5 day surgery wards for medical emergencies". That is how hospitals are getting by; they are just coping day by day.
At the same time, the Secretary of State has introduced a new patients charter standard--70 per cent. of trolley waits to be admitted within 90 minutes of the decision to admit. Another patients charter standard about to be implemented is that of choice--for elective patients to choose to come into hospital to a mixed-sex ward, or to choose not to come into hospital if the only bed available is in a mixed-sex ward or mixed-sex bay.
What the Secretary of State will not do is accept responsibility. She sets those standards but then walks away from them. She says that it is all the responsibility of the purchaser, while taking even more money away from the purchasers, whose hospitals have to resort to trolleys and mixed-sex wards only because the right hon. Lady will not fund them to open the beds that her cuts have forced them to close.
The pressure is not just on acute beds but, as was recently reported, on intensive care beds--and with tragic consequences. Out of the hospitals that I visited on Saturday, on a quiet night, only two intensive care beds were available.
All this has resulted in another sort of folly. I shall cite a specific instance of the problem being encountered by one of my constituents, who is a consultant at Bart's. For the past two weeks he has been trying to operate on a 75-year-old woman who has a desperately serious form of cancer. She has been in hospital for three weeks being prepared for major surgery. The first time her operation was cancelled was just an hour before it was due to take place, because the intensive care bed that had been booked for her had been taken by another patient. Exactly the same happened again last week and there are now real fears that her condition will begin to deteriorate.
The problem is that there are four high-dependency beds at Bart's that have never been opened, thus requiring intensive-care beds to be used when patients could be better and more appropriately nursed in high-dependency beds. That sort of folly is putting patients' well-being at risk and sabotaging the best efforts of dedicated staff.
Column 45Does she agree that the nub of the matter is the responsibility of the Secretary of State? Can my hon. Friend suggest any reason why evidence given to a Select Committee on the serious matter of the London ambulance service should not, after examination by the Secretary of State, be the subject of a reply from her to any hon. Member pointing out points of logic and matters of fact? The Secretary of State has a responsibility to do that and she should have said so during her speech.
Ms Jowell: My hon. Friend has made an important point. What causes us so much frustration, and what causes so much frustration and anger throughout London, is the extent to which the Secretary of State appears to have abdicated all responsibility for the chaos that she has created.
Every night, the folly of Ministers in refusing to accept the evidence is played out in the suffering of patients and the shattered morale of exhausted staff. All are victims of a Secretary of State who prefers to believe her own fairy-tale view of the world rather than confront the reality that she has created.
Florence Nightingale gave her name to the organisation of wards with beds in long straight lines--something that persists in some of our hospitals today. The Secretary of State has given her name to another sort of ward-- the Bottomley ward, where patients on trolleys are lined up in corridors waiting for beds to become free. What is also clear, and what was made patently clear to me during my visits on Saturday night, is that the confidence of both patients and staff has collapsed. So much for the primary-care-led national health service. Patients are voting with their feet. The loss of confidence among them means that instead of going to their general practitioners and facing what they know will be a long wait before a hospital appointment is offered, they short circuit that delay and go to the accident and emergency departments because they believe that that is the only way that they can be guaranteed seeing a doctor. There is also evidence that 999 ambulance calls are not always appropriate, but again it is for the very reason that people have no confidence that if they go to their doctor they will be referred to hospital before their condition becomes worse. They believe that the only sure way of getting into hospital is to phone for an ambulance to take them there.
There also seems to be evidence of a loss of confidence among general practitioners, which is shown by the increasing tendency to make an immediate decision to refer a patient to hospital. A few years ago, doctors might have kept patients under review for hours or days. However, they now know that their patients will have to wait, so they feel that it is better to get them on the list early. What is so dreadful about all this is that it is a direct result of ministerial action. The Government have gambled on the possibility that improved primary care will reduce the need for hospital beds. There is no evidence that that is the case; indeed, the contrary appears to be true. They have gambled on the belief that more work will be done on a day-care basis, thus reducing the need for in-patient beds. In fact, all the evidence shows that premature discharge after a day's surgery results in a rise in the rate of readmissions. The cynics would say that that might not be very good for the patients, but it increases the number of finished consultant episodes. That number goes up every time a patient walks through the door.
Column 46Hospital beds are being closed before the alternatives have been properly developed and their effectiveness tested in practice. It is a chaos of the Government's making, even on a quiet night in accident and emergency departments in London. As one sister put it:
"You want to do your best for patients but you can't, the pressure is too great, sometimes you cannot even get a patient a drink. We did not train as nurses only to be able to put sick people on trolleys."
If the Secretary of State continues to refuse to listen to the voice of the Opposition, or to the evidence that confronts her every day, perhaps she will consider the evidence in a report she commissioned from inner London chief executives. It said:
"On the basis of the evidence presented to us there are reasons for anxiety about the ability of the system to cope with a further round of bed closures without action to improve throughput and particularly arrangements for the care of the elderly."
I offer the Secretary of State another piece of advice. It comes from Robert Maxwell, in a press release about a report to be published by the King's Fund on Wednesday. He says:
"The pacing and sequence of change must take top priority. Because there is so little margin for error, there should be no reduction in services-- whether for those with acute conditions, for continuing care of elderly people, or for those with mental health problems--until alternatives are in place. Accident and Emergency departments should not be closed until other ways of dealing with their work load are secure."
That simply is what we are asking for. We are asking the Secretary of State to accept the advice provided by her own inner London purchasers, and to open the beds that she has closed to relieve the intolerable pressure on the patients of London.
Mr. Roger Sims (Chislehurst): The motion invites us to recognise "the Government's failure either to assess the health care needs of the area properly or to plan a programme by which those needs can be met".
I suggest that, in her speech, my right hon. Friend the Secretary of State for Health effectively refuted both those contentions. The facts and figures that she produced showed that needs have been assessed and that plans have been put in hand to meet them. The assertions in the motion are not true in the part of south-east London with which I am especially familiar--my constituency Bromley. What is happening in Bromley is not unique.
The health authority and family health services authority in Bromley have been working as one for several years, chaired by a very able lady and a most effective board of directors--which include a prominent local member of the Labour party--and run by a professional and energetic chief executive. Bromley health authority has assessed the needs of the local community and it has planned and begun to execute a programme to meet those needs.
Bromley health authority has carried out extensive surveys of the population, their health and their mobility. It has assessed the population's diverse health needs. It has undertaken public consultation and it has organised public meetings and private groups--a process that is continuing with small groups of local people being invited to show their expectations of local health services. As a result of that process, it has developed, among other things, a local rest care service. It has brought plastic
Column 47surgery consultants into local clinics. It has established a local alcohol detoxification service, run by a voluntary body, on whose management committee I sit. The authority has established local mental health teams and devoted extra resources to help promotion. All those policies have stemmed from local consultation.
The health authority has been pursuing the targets in the patients charter, especially in relation to reducing waiting times for both in-patients and out-patients. It has encouraged the use of day surgery. It has had to handle reduced funding, resulting from the operation of the weighted capitation formula, but it has remained within its cash limit and within its budgets. A part of the reason for that success is the operation of the internal market, criticised frequently, and in their motion, by the Opposition.
Bromley health authority has been able to improve the terms of the contracts that it has negotiated, both in the health authority area and outside it. For example, it has been able to save some £500,000 on placements in nursing and residential homes, without reducing the number of placements. The bulk of treatment is undertaken in the health authority area in four hospitals, some of whose facilities are in old and out-of-date buildings. Our great need is to have one modern, fully-equipped acute general hospital.
My right hon. Friend the Secretary of State will be aware that plans are well advanced to redevelop Farnborough hospital to produce a new hospital with the latest facilities for acute services, and with a modern accident and emergency department. I hope that, when those proposals come to her desk, she will give them a favourable response, so that my constituents can have the service to which they are entitled.
Even when we have our acute general hospital, and notwithstanding changes in the pattern of medical provision, which my right hon. Friend outlined in her speech, some patients from outer London and further afield will still come to inner-London hospitals, including Guy's hospital, for specialist treatment, as they have been doing for some years. I remind hon. Members that, some years before the Tomlinson proposals, discussions had been taking place between both administrative and clinical staff at Guy's and St. Thomas's hospitals to affect a rationalisation of services and a better use of the resources available. Those discussions, however, did not come to any consensus and, 12 months ago, my right hon. Friend the Secretary of State stepped in and issued what I think was described as a strategic direction.
I give my right hon. Friend all credit for at least doing something to try to break the logjam, but the more I consider her decision, the more I fear that it may have been based on inadequate and inaccurate information. The effect of her direction would be to close the accident and emergency department at Guy's, to move most in-patient services from Guy's to St. Thomas's, and to make Guy's mainly a teaching and research hospital. Not surprisingly, there was widespread reaction to those proposals, and it led to the setting up of the "Save Guy's Hospital" campaign, chaired by the hon. Member for Southwark and Bermondsey (Mr. Hughes), the local Member of Parliament, and co-chaired by the hon. Member for Dulwich (Ms Jowell) and myself. Hon. Members will be
Column 48aware that, among other things, the campaign promoted a petition that attracted well over 1 million signatures, and that was presented in the House just over a year ago.
Mr. Sims: I apologise--it was presented just over a week ago. It is a year that we have been working on this matter. The proposals and alternative suggestions have been the subject of detailed discussion and debate.
In the interests of other hon. Members who wish to make speeches, I shall not detain the House by going through all the considerations, but I shall make three points. First, hundreds of my constituents, and many of the constituents of my hon. Friends, travel daily to, and work in, the City of London. Surely the City needs an A and E department not only for the everyday accidents and illnesses that occur whenever a large number of people are gathered together, but for major incidents such as a terrorist outrage or a train crash, which might happen at any time in the City. With the closure of the A and E department at Bart's hospital, the continuation of an A and E facility at Guy's hospital is essential.
Secondly, thousands of patients throughout south-east London and, indeed, south-east England, are referred for specialist consultation and treatment to Guy's. They, their relatives and their friends have maximum ease of access to that hospital, which is sited literally next door to London Bridge station, with rail services throughout the south-east, and to a large bus station. Apart from all the other considerations, closing the facilities at Guy's and moving them to St. Thomas's would be very much to the disadvantage of a substantial section of the south-east England community. One feature of the Guy's site is Philip Harris house, to which reference has been made. It was designed and equipped specifically to provide the latest treatment and specialist services at a cost approaching £150 million. Surely it cannot be right not to use that building for the purpose for which it was constructed and equipped.
The "Save Guy's Hospital" campaign commissioned KPMG to report on the implications of the proposals and to suggest alternatives, and the campaign made its own proposals. They are being considered and will reach my right hon. Friend's desk in due course. I realise that she cannot comment now, but when it is time to reach a decision, I hope that my right hon. Friend will meet me and hon. Members from all parts of the House, together with those particularly concerned, to hear our views. I am sure that my right hon. Friend and my hon. Friend the Minister of State want, like me, to ensure the best health care for the people of London and the south-east.
Mr. Simon Hughes (Southwark and Bermondsey): I am grateful to be called, and grateful to the Labour party for choosing this subject for debate. We have been around this circuit before, but clearly it is necessary to go around again.
It will not surprise the Secretary of State and the Minister to hear that health care is chief among all the issues that currently preoccupy my constituents. That issue probably preoccupies Londoners most, too. Saturday's conference at the Queen Elizabeth II centre,
Column 49organised by the Evening Standard , was attended by more than 1, 000 people. That shows the interest and concern of the people living in our capital.
The hon. Member for Chislehurst (Mr. Sims) pointed out that that concern about London health care does not stop at the Greater London boundary. Traditionally, concern about London's health services is felt throughout the country and all over the world, because patients, students and practitioners are all part of the global network on whom the London health service has always depended and will continue to depend.
At present, there is a dialogue of the deaf. The motion say that there is a
"continuing crisis of health care in London".
The Government answer, "Oh, no, there isn't." The Government say that the health service is getting better. That gets the response, "Oh, no, it isn't." Somehow, the messages are not getting through. However well the Government think they are doing, they have not persuaded the public-- certainly not in the capital--that they are doing well.
Mrs. Barbara Roche (Hornsey and Wood Green): Is the hon. Gentleman aware that one of my constituents, a man of 78, had a prostate operation at the Whittington hospital cancelled because of lack of funds, and has been given no future date? While such incidents continue, the Government will find it impossible to persuade the people of London that they should have confidence in the capital's health service.
Mr. Hughes: Such incidents certainly lower confidence in the system. To be fair, the Government understand that. Recently, waiting lists in London have grown--there is no argument about that. Both the number of people on the lists and the time that they must wait have increased.
The public think that more money should be in the kitty for the national health service. I appreciate that this is not principally a decision for health service Ministers, and we heard an announcement today about more money, which is welcome. The Government must not be troubled by any belief among the public that money should not be spent on health care delivery, because the opposite is true. Opinion polls show that 80 per cent. hold that view. However, the public are suspicious about the £1 billion spent on the management sector of the NHS.
I am not arguing that London should get more than its fair share of the cake. A fair share is, of course, difficult to determine. It should be based not just on residence but on the number of outsiders who use the London health service--the hon. Member for Chislehurst and others spoke of such referrals. People are still not persuaded that the recently revised weighted capitation formula is just. It is not understood, and many suppliers and purchasers do not think it is fair. My local health commission believes that it should be given another £100 million a year. The money that is available is not shared equitably. The capital has a huge mix of deprived and not-deprived areas, and funds do not seem to reach deprived areas to anything like the extent they should.
The problem is not a lack of facts or accurate facts, but, because of their complexity, the facts are subject to all sorts of interpretations and misinterpretations. It is crucial that decisions are based on up-to-date, accurate facts.
Column 50Of course the Government's amendment is true to some extent, because Greater London's population has been declining. Of course it is right that people who do not need to come London are treated elsewhere. Of course there have been desperately needed developments in primary care. When the Minister visited my constituency, he saw a much better GPs' surgery than before, when it was in an old building down the road. However, we cannot spend more money on primary care--which I welcome- -to the detriment of necessary acute care for Londoners whose acute care centre is the district general hospital. If the figure for beds per capita in London is lower than the national average, and if waiting lists are larger and longer than the national average, I hope that the Minister agrees that the question is not the number of beds that exist but the number needed. At present, London does not have the beds it needs. I accept that fewer are needed than five, 10 or 20 years ago, but the current number is insufficient.
Beds are often 100 per cent. full. The inner-London chief executives have just said that 85 per cent. was a safe bed occupancy rate. The hon. Member for Dulwich (Ms Jowell) said that that is rarely, if ever, the case. I argue not for an ever-increasing number of beds but for enough, and not to make it look as though more patients are being treated by throwing others out so quickly that they must be readmitted the next day or week-- particularly the elderly--because they are prematurely discharged and returned home for inadequate care.
I do not oppose the idea of a review and of the Government saying, "We must grab the problems of London's health service by the neck and solve them." What I oppose is the fact that decisions are taken on the basis of information that is inadequate or inaccurate, and which is not then brought up to date.
I give a specific example. Professor Tomlinson now says that he was not given all the information he needed. The most contentious example is the fact that when he was shown the trend in the number of people admitted to hospital beds, he was shown only the figures for the most recent months before his report, and was not shown the figures for the period before that. The figures for the couple of months before the report showed a downswing, whereas the previous year's figures showed a consistent increase. Such a misunderstanding, which was not Professor Tomlinson's fault but a result of inaccurate information, led to conclusions that are now working their way through the system.
Since then, Professor Jarman has shown that Professor Tomlinson was wrong; Professor Tomlinson has admitted that he was in part wrong. In the past couple of weeks, the inner London chief executives have brought matters up to date since Jarman. On the radio this morning, the Minister said, referring to Tomlinson:
"nothing has really changed since then."
Some things have changed, and I can prove that to him. In addition, some of Professor Tomlinson's conclusions were wrong because he was misinformed.
Let the Minister have his review, and let him look at the evidence. I do not think that he is acting in bad faith. Let his evidence be accurate, and let it be updated by the facts. The review will then have the confidence of the people of London. The analysis must be right, and the changes must be brought into focus and accurately
Column 51represented. For whatever reason, many more people have gone into accident and emergency units in the past year than in previous years. I do not know why, but I know that it is a fact. If it is a fact, it must be taken into account.
I am not here to defend vested interests in the professions. However, specialists, who are perceived by the Government to have vested interests, are often specialists in great institutions, which are not only great institutions, but the places that treat the poorest and the most deprived in our communities. They are the most important institutions.
I have no compunction about saying in the House that the most valuable building in my constituency is Guy's hospital. Unarguably, it has done the most good for the most people over the longest period. The patients and the taxpayers are the only vested interests about which I am concerned--the people who pay for and use the service. What do they want?
The people who pay for and use the service want large hospitals for specialist services. I understand all the arguments about that and I understand that having small accident and emergency units without adequate back-up is no good. However, there is no theological answer to the question of what the right size is.
Above all, a different view should be taken about accident and emergency departments. Other specialties are much more high-tech and can be more limited in number around the country. There should not be replication of a service, whether oncology, renal services or paediatric services, between one hospital and the hospital next door, because that would be a waste of resources. There should be rationalisation and consolidation.
However, services that the community needs should be located where the community is. It is no good--taking the argument to its logical conclusion- -having a massive hospital with wonderful facilities that is not near enough to be of use to the people it is meant to serve. One cannot make decisions irrespective of the location of the communities and the users.
There is one other point about which I want to persuade Ministers. All acute general hospitals should have elective beds--beds that are not used for emergencies, to which people can be admitted to have operations for which they have waited. People should not have the experience of the constituent of the hon. Member for Hornsey and Wood Green (Mrs. Roche), who kept being told that he could not come in because of emergency cases. All acute general hospitals should have ring-fenced elective beds.
London communities are just as entitled to community acute health care as all other communities. Let us assume that my constituency has the same population as the county of Herefordshire. No one argues that people in Herefordshire should go to Birmingham for less specialist treatment. They should get treatment in Herefordshire, and the same point should apply to London. London also needs low-dependency beds and--this is hugely important --nursing homes and residential homes where there are low-dependency care opportunities for the elderly. In inner London, there are hardly any.
I want the Government to get things right. The problem is that people do not have confidence in the process because the precedent does not give them confidence. Many times, facilities have closed and we have not had a
Column 52replacement service to come to the rescue or, in many cases, a better service. People are, therefore, sceptical and need to be persuaded. Above all, if there is to be change, people need to know that the alternatives are in place and that they are working well. I conclude with the example about which, as the Minister knows, I am most concerned.
The Minister for Health (Mr. Gerald Malone): I have listened with interest to the hon. Gentleman, and I underpin his point that the momentum needs to be maintained. Before he moves on to what I know to be a subject close to his heart, would he tell the House what he thinks about Labour's proposal that there should simply be a review and a total moratorium?
Mr. Hughes: I can answer that question. I do not think that we can ever have a standstill, because the patterns of health care and of need never stand still. I am not arguing that we should stop everything for an indefinite period. I am arguing that there should be a perpetual review, with periodical decisions every five or 10 years, so that everybody knows what we are talking about. At the moment, we should work within a timetable set by the Government; they are perfectly entitled to set such a timetable. I shall suggest how we could take decisions in a way that would achieve the right results. I am trying to be helpful, because I believe that we have to break through some of the traditional failures in the health care structure in London.
We must have decisions that command confidence. I take the example of Guy's and St. Thomas's. According to the proposals, the accident and emergency unit at Guy's will not be run down until 1996 at the earliest. Ministers can go with the existing proposals and say that they will not look at things again. They can say that they will close the unit and that the provision will shift. That is setting one hospital against another. Such a decision set Bart's against the London hospital, and it is now setting Tommy's against Guy's. The decision sets people against each other, because it is taken by a few people behind closed doors.
Alternatively, Ministers could say, "This is the total money you will have. You work it out. You decide what your priorities are and where your services should be." The great benefit of that would be that the hospitals would have to work together and come to a conclusion. The Minister could say to us in south London, "This is the money; you will not get any more, because of the way in which the contracts work. You make the decision."
I guarantee that the GPs, the community health councils, the Members of Parliament, the local councils and the community would agree to make that decision. We would make decisions to rationalise across the Guy's and St. Thomas's sites, but we might well decide that the priority was to open Philip Harris house for its full purpose, and to keep accident and emergency units on both sites. I now turn to the reason why Ministers have to get it right. I am trying to help them not to get it wrong again. On 25 July 1991, the Prime Minister wrote to Peter Griffiths, who was then chief executive of Guy's hospital. He said:
"Thank you so much for helping to make our visit yesterday to Guy's Hospital such a successful and memorable occasion.
Column 53It was most interesting to learn more of the Guy's and Lewisham trust and its work. I was also struck by the positive attitude of not just the Board or senor management, but of all the staff I spoke to. I am sure Guy's will continue to lead the way in the development of the Trust concept throughout the country.
Norma and I would be grateful if you could pass on our congratulations to all those who helped to organise yesterday's `Topping Out' ceremony and visit."
That letter was written four years ago. Today, there is not wonderful morale at Guy's hospital, there is not great confidence that it will lead the world in the development of the new flagship concepts of the trust, and the local community does not feel reassured.
On 6 February, a note was sent internally to directors by two people in the local health commission, entitled "Meeting the Needs of the Residents of Bermondsey and Rotherhithe". In summary, it said: "We have demonstrated that the proposed acute changes will in the short-term make the poor health care provision in Bermondsey and Rotherhithe worse."
There is no excuse for the Government making decisions that make things worse. I hope that they will listen to those of us who are trying to ensure that they do not make mistakes, so that, for everybody in London, especially those who use the London health service, the health service can be better, as--I hope--we all wish to see.
Mr. David Congdon (Croydon, North-East): I welcome the debate. It is the third one on London's health in the past 10 months. It is unfortunate, however, that Labour Members have deliberately sought to exaggerate the problems in London to try to give greater force to their argument. I intend to outline what I consider to be some of the problems, because it would be foolish to try to pretend that there are no problems when change is being engineered and implemented in the capital city.
Any changes on the scale outlined in "Making London Better" and before those in the Tomlinson report, were bound to cause a degree of uncertainty. Change always causes uncertainty, and always causes fear. That has not been helped by Opposition Members--and, dare I say, some consultants and doctors in the hospitals concerned--whipping up that fear. It has made it much more difficult to conduct a rational debate on the important health changes in London.
No one likes to see great institutions under threat of closure. My plea to the Minister is that, while we must rationalise the provision the London--I shall say why in a moment--we should tread very carefully before we succumb to grandiose schemes involving millions of pounds of capital expenditure, on a wing and a prayer that they will lead to minor revenue savings.
I do not want to develop that point too much, but I make it with particular reference to proposals for St. Bartholomew's and the Royal London, which involve £250 million of capital expenditure. Coming from an outer- London borough, where we have always pressed for further developments in our district general hospital, as indeed has Bromley, the neighbouring borough, I repeat that we should tread with great caution before we accept such grandiose proposals.
We must also recognise that the status quo in London is not an option. It was interesting that the right hon. Member for Derby, South (Mrs. Beckett) did not say that this afternoon, unlike her predecessor, the hon. Member