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Column 67collects the most user-friendly, rather than the most accurate, statistics. One of his colleagues logged 36 appointments for eight patients. For statistical purposes, that was deemed to be 36 patient episodes and, therefore, 36 patients.
I am a great fan of "Coronation Street" and I try to watch episodes whenever I can. I do not expect, and nor do my constituents in east Lewisham or Londoners, expect to be considered as episodes like a soap opera. It is a contemptible device, by which the Secretary of State can pretend that the health service is treating more people when it is not.
I hope that the Secretary of State will listen to the Opposition, to patients in London, to nurses, to neurosurgeons and to the other staff of London hospitals. If she cannot listen to them, perhaps she will listen to the editorial of the Evening Standard today which says:
"Of course there are national problems with the NHS reforms; in London however these are aggravated by dogmatic hostility to the teaching hospitals, chronic underfunding and a profound inability to appreciate the scale of problems unique to a capital city. There is no room for complacency. This is an urgent situation which calls for acknowledgment and amendment from Government."
Let the Secretary of State for Health listen for once, not merely to us, but to the people of London and to London's newspaper, which held such a wonderful conference at the weekend. It explains today exactly why this debate is taking place--because of the crisis in health care in London.
Mr. Jim Dowd (Lewisham, West): I shall try not to delay the winding- up speeches too long. As the motion makes clear, more than anything else, there is a crisis of confidence in health care in London, especially in south-east London, and I am delighted to follow my good friend, the hon. Member for Lewisham, East (Mrs. Prentice). I was a member of the area health authority, as it was then, for Lambeth, Lewisham and Southwark in 1976 and went on to be a member of the successor district health authority- -it was disbanded in 1990--until I had to leave for having had the temerity to be an elected member representing Lewisham council. When I first joined the area health authority, there were at least 16 hospitals in Lambeth, Lewisham and Southwark. Today, there are four. At that time, there were six hospitals in Lewisham alone--today there is one.
As a member of the district health authority, I was deeply involved in the planning of what became known as Guy's phase 3--Philip Harris house, which has been mentioned. I took great pleasure in imagining that, one day, it would serve the needs of the people of south London and much further beyond in the ways for which it was designed. That will not happen now.
Trusts in south-east London need to be rebuilt. We suffered the first of the flagship authorities in the formation of Guy's and Lewisham. We were told at the time that Lewisham had to amalgamate with Guy's because it could have no independent existence worthy of the name and the matter was a fait accompli. The result of the consultation that took place was overwhelmingly against the creation of that trust, yet no notice was taken of it and the flagship set sail.
Column 68The Tomlinson report, which was merely a cover for the fact that, left to themselves, the market reforms would have severely damaged health care in inner London, then suggested that the Lewisham and Guy's trust could be broken and Lewisham could happily find its own way in the world as an independent trust. It said that Guy's needed to erect a new flag of convenience and amalgamate with St. Thomas's. If Lewisham did not have a secure future on its own in 1990, how could it have one in 1993? Either way, somebody was telling the people of south-east London less than the truth. Although the result of a consultation on the Tomlinson report was overwhelmingly against the setting up of a Guy's and St. Thomas's trust, once again that view was tossed to one side.
The consultation on the latest plan closed last Friday. Most people fear that it will lead to the closure of Guy's hospital in all but name and that all its services as a district general hospital will be extinguished. South -east London needs that district general hospital and the expertise and excellence that Guy's has come to represent. I implore the Secretary of State to make this a genuine consultation exercise, to listen to what people say and to consider the alternatives. Nobody says that nothing at Guy's must change, but that part of south-east London needs four district general hospitals to serve the community.
We need only look at the pressure that already exists at the accident and emergency departments of Guy's, King's, Greenwich and Lewisham, made worse by the closure of both Bart's and the Brook. The Brook hospital estimates a 20 per cent. increase in the pressure on the accident and emergency departments in surrounding hospitals and everyone in the area knows that those departments are not coping even now. Earlier speakers mentioned the fact that people are kept waiting on trolleys. A constituent wrote to me about her father, for whom even a trolley could not be found, who had to sit in a wheelchair for six hours at Lewisham hospital. It is foolish to believe that that position will do anything but deteriorate sharply if we lose the services at Guy's.
To understand that, one need only see the response of clinicians at Guy's about the safety of medical procedures if the A and E and intensive care departments are curtailed. I remember speaking to Peter Griffiths, who was general manager of the district health authority in 1986. He went on to be chief executive of Lewisham and Guy's and was famed for being the man who could drive two cars at once, because that is what he got for the job. He then joined the national health service executive. In 1986, he said that there would be a Government clear-out of hospitals in central London, and his job was to ensure that, whatever else happened, Guy's was not one of them. Sadly, he has failed, but the thrust of what he foresaw was patently clear. We need to save the services at Guy's, not just for the people of south-east London but for its reputation as a research centre, which will be seriously undermined if the watered-down scheme being advanced is proceeded with.
My final point is about the acute trusts and relates to what my hon. Friend the Member for Woolwich (Mr. Austin-Walker) said about accountability. I do not have the same problem with the mental health or primary care trusts, but getting responses to inquiries on behalf of constituents from any of the acute trusts is almost impossible. They respond only after they have been badgered time and again. I have occasionally been forced
Column 69to table questions asking the Secretary of State to tell them to reply. They do not reply because they know that they are accountable to no one for what they do and think that they can reply, or not, as they see fit.
I shall have to ask the Secretary of State to press the acute service to respond to a letter about a case with which I am dealing. I have had replies, but only once they have been pressed into replying, from the patient liaison manager; the operational and nursing director; the service manager, anaesthetics and intensive care unit service; and the chief executive, all of whom say that they will provide more information at a later date. That shows the insularity that they enjoy in their privileged positions, where they are cut off from the public whom they serve.
Others have said how the London ambulance service is scandalously failing to provide a proper service for the people of London, exacerbating people's problems when they eventually arrive at accident and emergency departments.
Despite Government figures, people know that London's health services are being damaged. That is not because we are spreading bad news to them; on the contrary, they come to us with complaints of what is happening to them and to their families and loved ones. It is patently clear that that is damaging the Government. On Saturday, I received a letter from a woman who said that it took 10 hours for her son to have an emergency operation at Lewisham hospital. She said: "I am afraid I never voted for you at the last election, but as my MP I would like you to take up a matter with Lewisham Hospital." She went on to say:
"I do not blame the doctors or nurses, but I do blame the bloated management and contractors for the poor state of cleanliness in the hospital--I will never again vote Conservative!"
That is what the experience of the NHS is doing to Government supporters.
The people of London need and deserve better from their health service. Once this Government are out of the way, they will get better.
Mr. Nicholas Brown (Newcastle upon Tyne, East): "I will never again vote Conservative" may be the most telling point to be made in this debate, and it has been endorsed by hon. Members from both sides of the House. Apart from the Secretary of State, only one hon. Member has spoken passionately and wholeheartedly in favour of the Government's current stewardship of health care in London. Every other speaker, with differing degrees of emphasis, has referred to his or her fears and concerns and, in the case of Opposition Members, expressed the belief that London's health care is in crisis. There is a financial crisis and a crisis in secondary care and in accident and emergency services. The promised shift to primary care simply is not happening. There is continuing underdevelopment of community health services, community care and services for the mentally ill. As my hon. Friend the Member for Woolwich (Mr. Austin-Walker) rightly said, the London ambulance service remains a cause for concern, three years after the Secretary of State first said that she would make it her personal priority. My hon. Friend the Member for Lewisham, East (Mrs. Prentice) rightly pointed out--the theme has been echoed by other hon. Members in the
Column 70debate--that there is neither an overview of services in London nor a recognition of the special and important features that affect health care in the capital.
Condemning the Government's stewardship of the capital's health care services is no reflection on the hard-working public servants in the health service, from consultants to those who clean the hospitals. We do not condemn the work, heart and energy that they put into providing health care in the capital. If they had the Government's support and the necessary resources, they could do a first-rate job, but they have neither the Government's support nor the resources.
I understand that Mr. Roy Lilley has just appeared on the early evening media speaking for the Conservative party about the nurses' pay rise and said:
"The money is there for the nurses local pay rise; but not for just turning up"--
which cannot be compared with Tory Members Parliament. That is not a fair way to deal with nursing staff, whose dedication is much admired on both sides of the House. I understand that the Secretary of State is hinting this evening that she is considering abolishing the pay review body if the nurses do not agree to a 1 per cent. national rise. If the Secretary of State is hinting at that, it is a complete disgrace. If she is not, although time is short, I will happily give way to her now to put all our minds at rest. Frankly, I will happily give way to anyone who can put our minds at rest, but I see that nobody is rising to do so.
I return to the theme of today's debate: the health care crisis in London. At the bottom of the crisis is funding. The allocation of funds to the capital's health authorities, as my hon. Friends have pointed out, has recently been recalculated. The new Government formula appears to benefit outer London at the expense of the inner-city areas. I wonder why. One does not have to think very hard about it. It is quite instructive to place a map of Conservative-held constituencies over one showing the just-losers in the redistribution formula compared with the heavy losers. I have no doubt that it is politically driven and that people who live in the inner cities will lose out. London's 16 health authorities stand to lose £111 million from their budgets over the next five years. That is a cut. As has been pointed out, the biggest losers are in the inner-city areas, with Camden and Islington the hardest hit with a loss of some 14.6 per cent. in purchasing power.
Spending on health care in London as a proportion of total NHS spending has fallen from 20 per cent. in 1988-89 to some 15 per cent. in 1995-96. London has about 15 per cent. of the population, so the Government will no doubt argue that the figures are commensurate, but that is not so, as I hope to show in a moment. The Conservatives do not make the same argument when talking about spending on London's police force. Although the population is the same, spending is 29 per cent. of the national total. Average health authority spending per head for 1994-95 shows London lagging behind Liverpool, Newcastle, Manchester--the other major metropolitan centres. There is also a shortfall in the spending per head on the family health services authorities.
London is a special case, not just because it is the nation's capital, but because it has the nation's largest concentration of inner-city deprivation. Half the entire United Kingdom population of drug abusers is in London. London has 60 per cent. of the homeless population and 75 per cent. of all known AIDS cases. The unemployment
Column 71rate in inner London is double the English rate. Inner London has three times the English proportion of poor housing and overcrowding. Some 25 per cent. of London's school children qualify for free school meals. Although Conservative Members try to resist the argument, there is a direct link between poverty and health. London boroughs account for seven of the 10 most deprived districts in the UK, as measured by the "Breadline Britain in the 1990s" survey. London boroughs account for 11 out of the 12 of the most deprived districts in the UK, using the Townsend deprivation index.
That has an impact on health. Inner London mortality rates are 25 per cent. above the English average. So London is a special case. The Government's claim to be redistributing resources from secondary to primary care is just not borne out by the facts. They are cutting the budget. The Labour party is calling for a moratorium, a chance to examine again the conclusions of the Tomlinson report. I know that the Minister of State will argue that it is a call for a review of a review, that it is, therefore, time wasting and that we should get on. That is what we are calling for. It is important. If the nation is marching in the wrong direction, it would be better to stop and think again rather than continue marching in that direction, which is the case that the Minister is about to advance on us.
It is our view that the Tomlinson report is flawed. In fairness to Tomlinson, however, he was not asked to examine provision for health care in the whole of London--he should have been--and his report deals only with inner London, and mainly with acute beds. He concluded that London is over- bedded. On that he is wrong. The most realistic figure that I can get--it is substantiated by the House of Commons Library--is that London has 2.5 acute beds per 1,000 of the population. I know that when the Minister responds he will quote a figure of more than four beds per 1,000 of the population, but to get that figure he is including every bed he can possibly find--no doubt including those in the private houses of Conservative Members. It is an exaggeration. The other argument that Tomlinson addressed is that London has 15 per cent. of the population but 20 per cent. of the expenditure. When one excludes the London allowance and the extra costs involved in the teaching functions of secondary care in London, the comparison is 15 per cent. of the population and 15 per cent. of the resources. There are other reasons why the Tomlinson report is flawed, but time prohibits me from going through them.
In summary, however, the report tries to treat inner London like an "average" English district, which of course it is not. It tries to suggest that increased primary care means fewer hospital patients whereas it may well not. One might well stimulate demand for secondary services by providing primary services. Tomlinson believed that patients from outer London did not use inner London hospitals. That, too, is wrong. Research by the King's Fund has shown that, of half a million in-patients treated in inner London, 150,000 came from outer London or other parts of the country. Tomlinson's calculations also failed to distinguish between the different types of beds--surgical and medical. The crisis is not just one of secondary care, but primary care as well. If the present rate of closure of London's psychiatric beds continues,
Column 72there will be none left by the year 2000. That cannot be the Government's objective, or the Secretary of State would never be out of the courts.
My hon. Friend the Member for Woolwich (Mr. Austin-Walker) referred to the London ambulance service. Some 37.8 per cent. of ambulances failed to arrive within the patients charter standard time of 14 minutes in London. What on earth is the point of having a charter if the service that is supposed to be supervised by it cannot live up to the results? The London ambulance service is long overdue for a thorough management review, as promised by the Secretary of State three years ago. She told me that it was to become a trust. The trust institutions are the Government's remedy for the problems in the NHS. If that is their preferred remedy, why has it taken so long for it to be put in place in the London ambulance service, where the problems are the most acute?
Mr. Spearing: My hon. Friend noticed earlier that the Secretary of State will not say--I do not know whether the Minister will--whether she will reply factually to the matters that I raised in my two memorandums. Surely the answer is there somewhere, and with the Select Committee on Health examining the matter in its inquiry, which both Ministers have pre- empted.
Mr. Brown: I am convinced that becoming a trust will not solve the problems of the London ambulance service, which seem to be management and technology driven rather than anything to do with the trust structure. If everything is all right in the London health service, why are waiting lists in London the longest in the country? When the Evening Standard sponsors a conference in association with the Association of London Authorities and the NHS Support Federation, why does it talk about the loss of beds, about there being fewer beds than in any other inner-city area, about the increase in waiting lists--just about everything except giving the Conservative party a ringing endorsement? It concluded by passing a resolution, part of which said:
"We call for an urgent independent inquiry, open to the public, to secure London's threatened health services, teaching and research."
That is not an endorsement of the Secretary of State's stewardship, but rather a plea to vote for the motion that the Labour party has tabled today.
The Minister for Health (Mr. Gerald Malone): I am grateful to the hon. Member for Newcastle upon Tyne, East (Mr. Brown) for leaving me some time in which to wind up an extremely important debate. The hon. Gentleman mentioned nurses' pay. I assure him that the Government do not wish to give any impression that they are thinking of abandoning the review body mechanism--an important mechanism set up some 14 years ago, all of whose report recommendations have been honoured. As the hon. Gentleman raised the point, let me also emphasise that there is money in the system to finance its recommendations. I hope that we shall be able to make progress in that regard.
I said this morning--when I was engaged in some broadcasting with the hon. Gentleman--that Labour's policy was a review of a review, and that is exactly what it is: "Let's mark time, let's do nothing." I hoped that this afternoon we might hear some intellectual underpinning for that policy. We heard a number of the constituency
Column 73points that Opposition Members would be expected to raise in an Adjournment debate, but we were not shown a broad picture of what Labour intends to do about London's health care problems. We heard no suggestions from Labour Members to deal with the over-provision of specialties and the future of medical education in London. We were not told whether they endorsed the movements that were taking place in the context of our policies; they said nothing about the way in which they would tackle the challenges posed by new technology to the provision of acute care in the city, and how rationalisation could take place in the light of such developments. I expected the debate to give the right hon. Member for Derby, South (Mrs. Beckett) an opportunity to address these matters anew. After all, she comes relatively fresh to her portfolio, and-- as Conservative Members know--she comes to it refreshed by a vigorous campaign for the Labour party leadership. She should be in full flow, exhibiting the drive that she exhibited during that campaign in her examination of the policies. I wondered whether, between that time and now, the right hon. Lady would screw up her courage sufficiently to secure a positive policy from her party. She tells us that she and her hon. Friends have looked at the matter in the round, consulted widely and called for a moratorium. I do not think that that suggests that a great deal of thought lies behind what they are saying.
I was about to say that it was interesting to note the contrast between what the right hon. Lady said and what was said by the hon. Member for Southwark and Bermondsey (Mr. Hughes), who at least conceded that movement was needed on all these fronts and that it would be wrong to arrange a moratorium and yet another review. When asked this morning about the time scale of the review, the hon. Member for Newcastle upon Tyne, East said that the review and moratorium would both take place when Labour was in government, "in perhaps two years' time": I dispute that. In any event, organising the review and moratorium would doubtless take some time. Even if Labour achieved office, it would be committed to a "do nothing" policy for London until the end of the century. It would simply fiddle while London's health stagnated.
Mr. Nicholas Brown: The Minister is having fun with what he parodies as our policy, but he is not telling us much about his own. We are merely asking the Government to stop and think. They are going in the wrong direction. We are saying, "Do not carry on--stop and think."
Mr. Malone: What London's health care needs is for a Government to act on the basis of information before them, and a positive agenda of bringing about change. I shall say more about that shortly. The right hon. Member for Derby, South had a choice when she embarked on her present responsibilities. She could have played a constructive part in the on-going debate about what should happen to London's health care, or she could have adopted the more fashionable course and joined the "London luvvies" campaign. They attend every demonstration; they come fresh to the scene, and
Column 74then depart pretty quickly. I am sorry to say that the right hon. Lady seems to have jumped on to the fashionable demonstration bandwagon, rather than contributing to a constructive debate. Much has been made about whether there has been a real transfer of recourse to primary care. The answer is that there has been, particularly through the London implementation zone initiatives: they involve numerous projects that have improved health care substantially in hon. Members' constituencies. I have seen quite a few of those improvements. I visited the constituency of my hon. Friend the Member for Croydon, North-East (Mr. Congdon), and observed the results of the donation of £30,000 to a mobile unit in the area. That and the provision of £118,000 for community dental services in Hackney are just two examples of many that are being supported by the London implementation zone initiatives--together with the £170 million in capital expenditure on primary care that is taking place over six years.
Earlier this week, I was pleased to be able to announce a £10 million education programme for primary care in London. Such initiatives will continue as primary care improves--and it is vital that that improvement takes place.
During the debate, we heard a number of suggestions about when the need for a change in London's health care originated. In fact, it happened rather longer ago than any hon. Member suggested. I can provide a quotation that underlines what is being done for London's health care extremely well:
"Never think that you have done anything for the sick of London until you have nursed them in their own home".
That is precisely the context in which we are moving care from the acute sector into the community, closer to people; but the quotation is not from Tomlinson or Acheson, but from Florence Nightingale in about 1880. She understood exactly what was wrong with centralised services that were not serving the community properly.
When the health care debate was well under way, the King's Fund said:
"The status quo is not an option, because Londoners need a first class 21st century health service system, rather than a decaying 19th century one."
The question is whether change can be managed, and whether transition can be given an impetus by Government. That is what is happening now, enabling the configuration of health services in London to meet the needs of Londoners.
However, the debate is also important to those who live outside London. It cannot be right for a single part of the country--no matter how much it may say that it deserves resources--to take up an unfair allocation. There has been considerable discussion of hospital beds today. The hon. Member for Newcastle upon Tyne, East is right: I shall cite the figure that he expected me to cite. In 1993-94, inner London had 4.2 available acute hospital beds for every 1,000 people; the national average was 2.3. That illustrates that a large management problem is involved in the spreading of resources around London's acute hospitals, and that it is time that it was rationalised.
London now has 43 major acute hospitals, each of which has more than 250 beds. It has far more than any comparable city. It also has far more specialist services, which consume a tremendous amount of revenue and capital resource. They are spread around the city, and
Column 75need reconfiguration. That is why rationalisation is required--and not in the impossible never-never time scale set out by the Labour party.
As for overall expenditure and commitment to the people of London, district health authority expenditure per capita in inner London is approximately 50 per cent. above the national average. Family health service authority expenditure, however, is approximately 5 per cent. below the national average. That demonstrates the need to ensure that the resource is transferred, over a reasonable timescale. Time will not permit me to answer a number of constituency points raised by hon. Members on both sides of the House. I shall read the Official Report and if any of the points require an answer, I shall supply one.
Opposition Members suggested that there was no funding for this transitional period. There is continual funding, both for the acute sector and for primary care. I mentioned the London implementation zone initiatives. In addition to that, £65 million of transitional funding is available for the acute sector. I completely deny any suggestion that what is happening is not being properly funded. The right hon. Member for Derby, South made what she thought was a rather amusing remark about hooligans on the terraces. We are the players on the pitch and the right hon. Lady is the hooligan on the terrace shouting to cause delay. The Opposition are hooligans with the oddest possible slogan. Hooligans usually shout, "Oh, ah, Cantona!" The right hon. Lady has a new one--"Oh, um, moratorium!"--but it will not wash.
Question put, That the original words stand part of the Question:
The House divided: Ayes 229, Noes 282.
Division No. 77] [7.00 pm
Column 75Abbott, Ms Diane
Adams, Mrs Irene
Ainsworth, Robert (Cov'try NE)
Banks, Tony (Newham NW)
Beckett, Rt Hon Margaret
Beith, Rt Hon A J
Benn, Rt Hon Tony
Bennett, Andrew F
Bray, Dr Jeremy
Brown, N (N'c'tle upon Tyne E)
Column 75Campbell, Mrs Anne (C'bridge)
Campbell, Ronnie (Blyth V)
Campbell-Savours, D N
Clarke, Eric (Midlothian)
Clarke, Tom (Monklands W)
Clwyd, Mrs Ann
Cook, Robin (Livingston)
Cunningham, Jim (Covy SE)
Cunningham, Rt Hon Dr John
Davies, Bryan (Oldham C'tral)
Davies, Ron (Caerphilly)
Davis, Terry (B'ham, H'dge H'l)