House of Commons Hansard Debates for 21 Feb 1995

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The Minister for Health (Mr. Gerald Malone): I am pleased to be able to respond to what has been a short debate on an important matter. It is obvious that those of my colleagues who were sitting, hanging on my every word in Committee, have been entirely convinced by the debates that we had on that occasion.

The right hon. Member for Derby, South (Mrs. Beckett) talked about the "cloak of secrecy" which will be introduced with the passage of the Bill. I reiterate what I said in Committee: nothing could be further from the truth, and I welcome this opportunity to set out how the arrangements will work.

The regional offices will be an integral part of the NHS executive and, therefore, part of the reporting arrangements which are already in place for the Department of Health through the departmental annual report. That is not simply a report which is issued to the public; it is a Command Paper which is laid before Parliament and is available to the public. It describes in detail the Department's activities and expenditure across all its responsibilities. The right hon. Lady said that information would be concealed, but the opposite is the case. The Department remains accountable to the House through its annual report and I cannot think of any stronger accountability than that. The right hon. Lady also said rather curiously, in an antithetical way, that all roads lead back to the Secretary of State under the new structure. They do, but the right hon. Lady cannot have it both ways. She argues one day that the national health service structure is not accountable either to the Secretary of State or to Parliament because the Government have fragmented it and sent it off in all sorts of directions, ending up in institutions which act on their own initiative and are accountable to no one. We sometimes hear that speech on a Monday afternoon, only to hear the right hon. Lady say on a Tuesday--as she has today--that all roads in the health service lead back to the Secretary of State.

Ultimately, all roads lead back not just to the Secretary of State but to the House, to whom Ministers are accountable. During that part of the Committee proceedings which I was fit and well enough to attend, I was at pains to emphasise the fact that that responsibility is extremely important and is taken very seriously.

Further information about NHS executive activities is made public through a wide range of publications, such as the NHS annual report. Further reports are planned, including a series of quarterly reviews which will start in May this year, an NHS quarterly magazine which will replace "NHS News" from June 1995 and, as the right hon. Lady knows, a range of statistical bulletins and issues-based newsletters concerning the performance of the service.

It is entirely wrong for the right hon. Lady to suggest that a "cloak of secrecy" surrounds the NHS. I think that there is more like a blizzard of information which is published directly either for the purposes of the House or for those who are keen to research those matters in their or the public interest, as well as for the general public. That approach is right and proper and it will continue under the new structure.

Mrs. Beckett: In making his remarks, I think that the Minister should address who controls the information that

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is supplied. He says, quite correctly, that a blizzard of information is coming from the Department; but if one is so unwise as to request information which is not couched in precisely the form in which the Secretary of State chooses to release it, that information is not forthcoming.

I do not think that anyone--except perhaps a Minister in this Government-- could defend the fact that the Department of Health does not, for example, collect statistics about the current number of hospitals, how many accident and emergency units are threatened with closure, or what the pattern of provision of such health care should be across the nation. That is exactly the kind of information that is collected by regional offices because, as regional health authorities, they have a separate duty to the public. All that information will now be controlled by the Secretary of State, and precedent suggests that she does not tell anyone anything that does not suit her purposes.

Mr. Malone: The right hon. Lady is entirely wrong about that issue. Information must be collected for statutory purposes--for example, to fulfil the requirements of the Public Accounts Committee and the Audit Commission and to report to the House through the departmental annual report. I regret that the right hon. Lady and her hon. Friends sometimes table questions in a way that does not allow me to answer them, simply because information is not available in the form requested. There are occasions when we puzzle over the questions, and only after conversations with the right hon. Lady's researchers are we able to guess at the purpose of a question.

Mr. Nicholas Brown (Newcastle upon Tyne, East) rose --

Mr. Malone: We do what we can to answer and to be as full and frank as possible on every occasion. In that spirit, I give way to the hon. Gentleman.

4.15 pm

Mr. Brown: The whole House has obviously caught the Minister in a good mood and that is to be welcomed. If he is saying, as he has on countless occasions, that information is not held centrally and, therefore, the questions that we table seeking factual information are not properly worded, perhaps he will assist the whole House by telling us in plain English how we could table a question to find out how many hospitals there currently are, how many his Department has closed and how many his Department plans to close.

Mr. Malone: To answer the hon. Gentleman's last point first, we do not keep statistics on hypothetical questions. The other points that he raises relate to matters of definition--for example, what one defines as a hospital. There are many institutions that he may define as a hospital, that perhaps a member of the public might not define as a hospital, where information is held. The Government would never mislead the hon. Gentleman in any way by giving him any information that could not be precisely defined.

While I have the opportunity to engage the hon. Gentleman's attention on this point, I hope that he will recollect that when questions are tabled, perhaps some regard could be had for the public expense incurred in answering them. I say that not about questions that seek

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genuine information but about those that repeat what has been asked, sometimes a week previously, by his hon. Friends, and answered. I should also mention questions which are clearly trawling exercises for the purpose of basic research and on which published information is readily available. On one occasion, 155 questions were tabled in one day, at huge public expense and involving huge consumption of management time. I hope that we can use the debate to achieve a modus operandi so that public cash is not wasted on consuming health resources, which could otherwise be spent on patient care, by littering the Order Paper with what is essentially unnecessary.

Ms Ann Coffey (Stockport): Is the Minister saying that, in future, he will not be able to answer questions about hospital closures because his Department no longer has a definition of a hospital? If so, that will be an interesting debate.

Mr. Malone: I shall be guided by better information than the hon. Lady suggests. Certainly that would not apply to matters which are ultimately the Department's responsibility and in which regional offices are involved, especially where such matters are referred directly to Ministers. Of course we shall continue to answer questions on those matters.

Mr. Kevin Hughes (Doncaster, North) rose --

Mr. Malone: Before I move on, I shall give way to the hon. Gentleman, as I am in an extremely good mood this afternoon.

Mr. Hughes: I am grateful to the Minister for giving way and even more grateful for his good mood. How does he define a hospital? It is interesting that the definition of a hospital is no longer what it used to be. I would be grateful if the Minister would say what he means by a hospital, so that not only Opposition Members but everybody else can be clear about just what it is.

Mr. Malone: The hon. Gentleman's uncertainty underlines my point that it may not be sensible to try to hit on a precise definition. Opposition Members have often said--the right hon. Member for Derby, South repeated it this afternoon--that the move from regional health authorities to NHS executive regional offices, which will be part of the service, will mean a loss of openness. The right hon. Lady asked specifically what would happen to reports from directors of public health. As I believe I said in Committee, regional directors of public health will not publish reports, for the simple reason that the function that they currently exercise will be devolved nearer the population, to health authorities. They will continue to make reports, but in the context of the health authorities. I hope that I have finally got the point across to the right hon. Lady.

I hope to persuade the right hon. Lady that, as directors' reports will be made at health authority level, they will be far more relevant to smaller population groups. That is important when we are trying to identify and address health needs on an

authority-by-authority basis. In any event, regional offices are not the bodies that need to be independent, as the right hon. Lady suggested. They will not make the decisions that will affect local people directly--the new health authorities will make those

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decisions. They will be independent in the same way as regional health authorities and, in addition--under the codes of conduct and accountability issued in April 1994, which we discussed a good deal in Committee--will be expected to produce and publish annual reports. The regional offices will have a monitoring role. They will contribute to the development of central policies for the NHS, influencing the policy-making process by offering advice to Ministers. It is entirely appropriate for such tasks--including any that involve the collation of reports from health authority public health directors--to be performed by civil servants, who will be part of the process that requires direct accountability to Ministers. As for centralisation, as a result of the 1990 reforms responsibility has already been successfully devolved from regional health authorities to a level that is closer to patients. The Bill will devolve it still further by moving vital functions, such as non-medical work force planning and many public health functions, down from RHAs to the new health authorities.

The right hon. Member for Derby, South said that the reforms had not been thought through. In Committee, we did not discuss which functions would reside where after the enactment of the Bill. I shall not detain the House by repeating the lengthy statement of functions that I made in Committee, but I draw it to the right hon. Lady's attention. It seemed, if not to satisfy the Committee, certainly to silence it--which, at the time, I may have interpreted as something rather different.

The right hon. Lady referred specifically to training and employment contracts. The Committee dealt with that in some detail, but for the sake of certainty I shall reiterate the position. The education contracts of registrars and senior registrars will be held at regional level by postgraduate deans; in Committee it was widely conceded that that was by far the most important aspect of the contracts, and the main source of concern.

Future arrangements for the holding of contracts are still under discussion, but, as I said in Committee, that is more a technical matter. The fundamental issues were what would happen to education and who would guarantee that doctors could move around the system to secure proper training. I welcome this opportunity to tell the whole House that postgraduate deans will have that responsibility. I simply do not accept the premise from which the right hon. Lady starts--that this addition to the Bill is necessary. It is not true that less information is available on the service than before. Under the new national health service, far more information is available than ever before. Trusts are accountable to their patients and must publish annual reports. Across the country, more information exists about the performance of the health service in terms of waiting lists and of the quality of institutions that deliver health care, and it is much more widely available than in the past. Much of the debate that we have in the House and elsewhere about how the health service is performing involves information that is used by Opposition right hon. and hon. Members. In years past, under the old NHS, the lack of information would not have allowed such a debate to take place. The combination of annual reports, accounts and league tables--vital information that tells us how public money is accounted for, and how it is translated into patient care--is accessible not only to hon. Members but to a wider public. The new clause is not necessary. The service

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will ultimately remain accountable in a proper way to the House. Perhaps, although I fear that this is a forlorn hope, the right hon. Lady will seek to withdraw the motion.

Ms Coffey: The new clause seeks to make information available. I note the Minister's comment that he thinks that information is already freely available. He mentioned that the information will be available in the annual accounts of trusts, but I understand that the trusts' annual reports will be late this year. I have no clear idea of when my local trust's annual report, which will make all this information available to me, will be published.

In Committee, I raised the issue of the £215,000 that has been spent by my health care trust on set-up costs. I have failed to obtain information from the trust's chief executive on how that money was spent. That is clearly symptomatic of the problem that Members of Parliament have in obtaining information from trusts. In a letter to me, the chairperson of the local acute services trust, said: "As far as accountability is concerned I am directly accountable to the Minister who is of course accountable to Parliament for the trust's action".

Why is it then that, when I write to the Minister about some aspect of my local trust, he refers me back to the trust? Somehow, this wonderful circle of accountability does not go the circle. The £215,000 is public money, and was given to the trust for set-up costs. I have consistently asked the simple question: can the chief executive tell me how that £215,000 was spent? He has refused to tell me. He has referred me to the annual report. That seems illogical: if the information will be available in the annual report, why cannot the information be available to me now?

Mr. Malone rose --

Ms Coffey: The Minister is going to tell me.

Mr. Malone: I ran through an analysis of start-up costs in Committee. I cannot give the hon. Lady a breakdown of the figures precisely in relation to her own hospital, but I will be delighted to consider that matter and to give her whatever information is available. I will write to her on that point.

I have no idea where she gets the suggestion that reports will be published late--that is news to me. When those reports are published, more information will be available, for example, on management costs. That is an important step forward, which she would doubtless welcome, because Opposition Members question the service about the proportion of funding that is being spent on those costs. I hope that that underpins the serious intention of the Government to disclose, wherever possible, as much information as possible, so that the true performance of trusts will be publicly visible beyond the service itself.

Ms Coffey: I was told that the annual accounts were to be late in a letter from one of the Ministers in reply to my letter asking why the information about the £215,000 was not being given to me. He referred me to the annual report, and said that it would be late. I should be happy to show the Minister the letter.

I welcome the fact that the Minister intends to give me a breakdown of the £215,000 set-up costs. I should be happy if the Minister would tell the chief executive of my

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local health care trust that the information should be made available to Members of Parliament. That would be a great step forward. I am sure that the chief executive believes that, by not giving me the information, he is in some way carrying out the Government's wishes. Clearly that is not right, and he must be made aware of that, as must all chief executives of trusts.

4.30 pm

The main issue I wish to raise with the Minister deals with the monitoring of the programme to discharge mentally handicapped people into the local community once the regional health authorities have been abolished. As the Minister is aware, the programme has been going on for several years and involves closing down institutions such as Cranage or Offerton house in my constituency, which for years nursed mentally handicapped people in an institutional setting. Over the years, that programme has been the subject of some financial dispute and argument between local authorities, district health authorities and regional health authorities. The arguments involved the money for those patients--it has been referred to in the past as dowries--as well as arrangements for financing the entire programme, including complicated deals about the notional value of regional health authority land and the selling off of that land. The programme is almost complete: effectively, the regional health authority programme has transferred to the health authorities, and people with mental handicaps are living in houses in the community. Financially, they are living as normal people, entitled to housing benefit and other benefits. Care is being provided by the health authorities and, in my locality, staff employed by the health care trust go in on a daily basis to care for those people.

The patients are highly dependent; some of them have been living in institutions for many years. Therefore, transferring to the community can be difficult. The care they need must be of the highest quality, because, however much we talk about them living as normal people, their needs make them special. They are a risk to themselves: unfortunately, in Stockport recently a mentally handicapped person died in one of those homes.

The care provided is paid for by the local health care trust, which also employs the staff. As far as I can see, this has nothing to do with the Stockport health commission, and there is no commissioning role in buying the care. It is provided through the money from the regional health authority, and has ended up with the health care trust.

I can see several problems with this. If the Government felt able to accept the new clause, I believe that some of the inherent difficulties and conflicts might be resolved. A local health care trust should not be responsible for employing staff and providing care, because the cost of that care and the staff come out of the same budget.

I was quite concerned to see an advert in my local paper, which asked for staff and said that experience with mentally handicapped people was desirable but not necessary. A cynical thought passed through my head--of course, it costs less to employ unqualified people than qualified people. The ratio of unqualified to qualified people in Stockport is on a balance with the unqualified people who are employed part-time on a bank staff basis, where at the beginning of the week they are sent here,

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there and everywhere, depending on where the need is. That, obviously, is cheaper than employing full-time or fully trained staff.

There is an inherent conflict, because if there is pressure on the budget-- and there was last year--what better way of saving money is there than by employing less qualified staff on a lower rate of pay? That is not right, because mentally handicapped people who come into those homes have care plans, and the same authority that supplies and employs the staff monitors that care plan.

That cannot be right. There seems to be no independent inspection. There are no targets laid down by the Government about the quality of care. The homes are not subject to inspection, because they are not considered to be residential homes. The health and safety regulations do not apply. The homes are, in fact, operated as mini-institutions. I am concerned about the quality of life for people in those mini-institutions. I have always supported the ideology behind community care--that institutions are not homes for people, and that it is better for people to be in a home and for care to be put into that home--but surely quality must be addressed. If mentally handicapped people in those homes are not provided with day care or stimulus outside the home, and if day care simply means providing them with Sky Television 24 hours a day, I am concerned about the quality of care, because that is not what community care is supposed to be about.

Who assesses whether the quality of care for those people is better than that in the hospital in which they were previously resident? Community care is supposed to be about improving the quality of people's lives. Where, and by whom, is that judgment made? I am concerned, because of the abolition of the regional health authorities, and the duties of the new regional offices not being clear by any means, about how the programme is being monitored across the country. Monitored it must be, and properly inspected. Mentally handicapped people need protection. They cannot speak for themselves. There must be some independent inspection of their needs and the quality of their lives.

I am not sure how the Minister will address that question and what input the regional offices will have. If there is a commissioning body--a health commission--and a provider unit, as in the trusts, in a sense there is some inspection by the health commission, because it purchases care and can demand to see the quality of that care. But if the provision and purchasing of the care happens within the same organisation--for example, the trust-- which appears to be the case in the care of mentally handicapped people, I suggest to the Minister that will stack up problems for the future. There must be some way in which to provide some independent inspection, whether that means, when the regional health offices go, placing that role back into the health commission and giving it the responsibility of commissioning care for mentally handicapped people. Perhaps that is a way round it. I am sure that it is not the only issue that needs to be dealt with, but it is in my thoughts, as this is happening in my constituency. No doubt other hon. Members could think of a number of other issues to be raised in this context.

The problem is that it is not clear what the regional offices will be monitoring, and what their responsibilities will be. At one level, this important Bill may seem uncontroversial, but I suspect that it will have far-reaching consequences for the delivery of health care. It therefore

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seems especially regrettable that it does not contain sufficient clarity. As we have discovered, we sometimes pass legislation without paying sufficient attention to its consequences.

The new clause offers a safety net by ensuring that proper monitoring takes place and that appropriate information is available to the public. The Government claim to be in favour of access to information, so I do not understand why they do not support the new clause and ensure that information is open to the public.

Mr. Martin Redmond (Don Valley): I apologise to the Minister of State for having missed the beginning of his speech, but I was upstairs at a meeting of the Carers National Association, listening to the trials and tribulations experienced by its members because of Government policies.

My remarks all relate to accountability, or the lack of it. There is going to be no accountability in the national health service. The regional health authorities are to be kicked into obscurity, and their replacements will mean an absence of accountability. Brian Edwards, who used to be the secretary of Trent Regional health authority, has moved up into the money markets, and we have heard a great deal recently about people who have done extremely well. Let us consider the appointment of the chairman of the trust in Doncaster and of the people who sit on the board. It is remarkable that those people do not represent a cross-section of the community; it seems that only people from a certain clique are wanted. The Minister and the Secretary of State must take responsibility for such appointments. For there to be accountability, the people who sit on trusts should be under no obligation to the Conservative party. Due consideration should be given to the secretaries and chairmen of the community health care councils sitting, as of right, on trust boards.

In the old days of the area health authorities, the press were invited to attend meetings, and the only matters from which they were excluded were those that required patient confidentiality. That is the only way to be open and above board, and avoid the sort of scandals about which we have recently heard so much. I am all for reform and progress, but making progress means going forward, not back to Victorian days.

I have been to hospital in the past couple of years, and have been fortunate enough to receive excellent treatment from nurses and doctors. Indeed, were it not for their skills, I should not be here now. I have much to be grateful for, and I am sad to see the health service, which I love, being dismantled because of the Conservative party's political dogma.

The Doncaster health authority used to spend about 3.5 per cent. of its budget on administration costs. I suspect that, were the Minister to do a similar calculation of the trusts' administration costs, he would find that the figure was more like 8 per cent. I am guessing, but it is an educated guess. In any event, it means that a tremendous percentage of available funds is not being spent on patient care. 4.45 pm

I believe that there is more accountability and openness among the Freemasons than in the health service. [Hon. Members:-- "How do you know?"] I live in the real

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world of the doctors and nurses. I hear the Minister, the Secretary of State and Conservative Members expound the benefits of the new arrangements and talk about money in "real terms", but I lie in bed at night adding up the hours that junior doctors spend on the wards, and they are unacceptable.

The general waste and handouts to get rid of bad appointees as chairmen of authorities all adds to the lack of accountability. Conservative Members should go out into the real world and talk to nurses and doctors, not the lackeys appointed by the Secretary of State. Patients praise the dedication of the nurses but condemn the money wasted on administration. Accountability is important, and the Conservatives need to understand what is really going on.

Mrs. Bridget Prentice (Lewisham, East): Once again, I stress the need for a strategic health authority for London but the Bill as drafted does not allow for the accountability that Londoners need in terms of their health care.

My remarks are intended as an act of kindness. In London, as elsewhere, the Government are singularly unpopular and have wholly misunderstood what people in London want. We are giving them the opportunity to rectify that. I hope that the Minister will accept the new clause as a measure of good will and take it as an opportunity for the Government to join us in seeking to provide a strategic health authority for London. It would be a popular decision among Londoners and would go some way to meeting London's health care needs. The chances are that my words will fall on deaf ears yet again, but I live in hope that one day even the Government might listen to Londoners.

Yesterday, I listened carefully to the Secretary of State's speech on the health crisis in London. She talked at length about what was happening in London as a whole. I should have thought that even her comments made it clear that there is a need for strategic thinking when planning health care and health provision across London. It is not just that the capital city needs strategic planning--it does fundamentally. Strategic planning is important because the needs within London as a whole and within inner London in particular are so much greater than they are elsewhere.

The Government often like to divide London from the rest of the country on the ground that London is over-resourced compared with the rest of the country. A number of the reports that have come out in the past year or two --certainly since the Secretary of State began her reforms in London--show that the Tomlinson report, on which the Secretary of State has based her slashing of services in London, was flawed because it was based on a great deal of misinformation, inaccurate statistics and unfounded dogma.

Not only Professor Jarman but others have shown that the acute bed need in London is great, that waiting lists are now rising rapidly and that the health needs in London are significant compared with those elsewhere. London obviously has the highest level of homelessness in the country. I use the word "obviously" because people are attracted to the capital city, which is one reason why homelessness is so bad in the capital. There is also more pressure on housing to rent in London than there is elsewhere. Young people in particular have no

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opportunity to get decent housing. Every medical expert tells us that homelessness has an effect on people's health. The level of homelessness is one way in which London is unique compared with the rest of the country.

As a number of my hon. Friends have mentioned in other debates, London has the highest level of people who are HIV positive or who have Aids-related diseases which require specialist care in hospitals, in people's homes and in community care facilities. Such specialisation is costly, but it is necessary and we must do all that we can to ensure that whatever the resources available for people who are HIV positive or who have AIDS, they are made available to people when they need them.

The capital also has the highest level of drug dependency in the country. This is a specialist area and we need to consider how to get resources to people as quickly as possible so that we can help them to survive. The amount of poor housing in London, the extent of homelessness and a series of other factors mean that other debilitating diseases are more prevalent in the capital city than elsewhere.

The comments of the Secretary of State suggest that a strategic health authority for our capital city is vital. It is extremely sad that the Government have ruled against any possibility of such an authority being set up. Instead of setting up that strategic authority, as they could have done under the Bill, they have removed the present level of accountability, small though it is, to the regional offices. That will not reflect the needs of people in London.

The Bill will have an especially dire effect on two areas. The Secretary of State has talked a great deal about care for the elderly and she appears to be terribly proud of her community care policy. In my experience and in the experience of many colleagues on both sides of the House, care in the community is simply not working in London. When elderly people are discharged from hospital and sent back to their homes, often with only an elderly, frail relative to care for them, there is little back-up and little thought is given to the resources and resource management that are needed to ensure that people can recover properly from whatever illness put them in hospital in the first place. Some people have to go back to hospital for a second or third time and others, sadly, do not survive the experience at all. Unless we have a strategic overview of what happens in our hospitals in London and of what happens when people are discharged from hospital into their local community, we shall not serve the people of London well.

I now turn to mental health. My hon. Friend the Member for Stockport (Ms Coffey) mentioned mental health and spoke about the needs in her area. London has a greater need for mental health services than elsewhere. There are examples, right across the capital city, of people being discharged from institutions into the community without any resources to back them up. There have been a number of tragic instances.

A few weeks ago, a woman, who was not a constituent, came to my surgery. A relatively young person with a mental illness, who had been discharged into the community, attacked her when she had three children under five with her. Although she was not badly injured, it was a frightening experience and one that neither she nor anyone else would want to have. She recognises, as

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the rest of us do, that the reason why such incidents happen is that there is no proper resourcing of community care in the city. People should be discharged from institutions only if the Government are prepared to put resources into the local community to enable care to be given properly. Some time ago, there was the tragic affair of the Clunis report, with which the Guy's and Lewisham health trust had to deal. There have been many other cases which hon. Members can cite.

There is growing concern in the capital city that although people who have mental illnesses and those who are drug dependent or have some other specialist problems are more prevalent in London than elsewhere, they are not being properly looked after. The hospitals are totally under-resourced and we need to find a strategic way in which they can be resourced. Just before Christmas, there were examples of people with mental illness being shipped 50, 60 or 70 miles away because there were no beds in London in which they could be cared for.

The Government seem to be committed to ignoring what Londoners want. The new clause would enable the health service in London to become more accountable. That would go some way towards alleviating many of the fears of people in London about the state of the health service here.

I now touch on another aspect of accountability which I raised in Committee and which still concerns me because I do not believe that the Government have recognised the seriousness of the situation. I refer to the universities having a place on the health authorities. At present, they have a place on the existing health authorities as of right under a statutory provision. Under the Bill, that statutory place will be removed.

That will be a tragedy not just for the universities, which are well aware of the problems that will arise, but for the new health authorities. They will not have the direct expertise of the medical practitioners and the academics in the universities who know about their teaching methods and about their teaching programmes, and who can influence and support the health authorities to ensure that they dovetail their programmes of work with that of the universities. Listening to the Secretary of State yesterday, I found it rather strange that she spoke eloquently about the centres of excellence and about the importance of our educational and academic training for doctors, in London in particular. The Secretary of State said: "I am also strongly committed to our international position and centres of excellence."

She said later in the debate, when talking about the importance of education and research:

"Those are fundamental to the reputation of London as a world leader in medical teaching and research."--[ Official Report , 20 February 1995; Vol. 255, c. 37-41.]

In that case, it strikes me that we ought to acknowledge teaching and research by ensuring that those academics are involved in the process of decision making in the hospital service.

Mr. Malone: I would not like the hon. Lady to give the House the impression that this matter has been disregarded and was not discussed in Committee. Of course it was and I pointed out in Committee that, if a medical school is in the area of the health authority, there

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would be a medical school representative, a university representative, on the board. I made that absolutely clear. However, like every other board position of that sort, it will be prescribed in regulation. Perhaps the hon. Lady's debate is over whether those positions should be in regulation or in the Bill. She is giving the impression that there may not be representation at all. It is certainly the Government's intention--I gave an undertaking to that effect in Committee-- that there will be such representation.

Mrs. Prentice: I am grateful to the Minister for making that clear. I was not clear about that in Committee. Although, as the Minister would expect, I disagree with him over the provision being prescribed in regulation; it should be in the Bill, but one step at a time is perhaps as much as we can hope to take with this Government. I believe such representation to be important. I have a special interest in training in general and, in this context, in medical training in particular. The fact that it will be purely under regulation and not a statutory requirement evokes fear for two practical reasons. First, when hospitals are being

rationalised--closed, to those of us who understand the term--it is very important that universities are centrally involved in decision making because the costs involved of moving staff and medical students from one hospital to another can be enormous, as some hospitals elsewhere in the country have found.

Secondly, universities fear, and justifiably so, that the Department for Education, which presently funds the moving of the medical training and therefore funds part of the health service, will say that it will not fund such future moves. Yet we must feel confident that universities are aware right from the start were such funding to cease, so that they can participate in the process and be party to events.

As I said, the costs of changes can be enormous. It cost £15 million in Oxford, £20 million in Glasgow and Edinburgh--

Mr. Deputy Speaker (Mr. Michael Morris): Order, I was hoping that the hon. Lady was coming to the end of that part of her speech. Frankly, the new clause does not apply to matters concerning the Department for Education.

5 pm

Mrs. Prentice: I am trying to establish the fact that the Department for Education funds part of the health service through the university medical schools, which is why accountability is so important. University medical schools need to be able to speak directly to the Department of Health about what is happening--

Mr. Deputy Speaker: Order. I was listening to the hon. Lady and I was well aware of the point that she was making. It is perfectly proper to make an aside, but she is developing the argument. I hope that she will now desist from that and return to the main thrust of her speech.

Mrs. Prentice: I am grateful, Mr. Deputy Speaker, and I shall move on, because the Minister has responded, to some extent, to my point. I hope that, in responding to the debate, the Minister will remember that that aspect of accountability is centrally important if we are to ensure that those centres of excellence, which the Secretary of State discussed

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yesterday, remain. I hope that there is accountability in medical education, and especially as an hon. Member who represents a London constituency which suffers great deprivation and has large demands, I hope that we consider again the need for a strategic authority in London to provide the accountability in their health service that Londoners want.

Mr. John Gunnell (Morley and Leeds, South): The two new clauses are excellent, and I urge the Minister to look at them carefully and to consider accepting them. They would strengthen the health service and provide the Department of Health with a much better defence against the proposed reforms than they have been able to put up against the reforms which have already been implemented.

The new clauses are strongly linked and deal specifically with accountability, as most hon. Members who have spoken said. Accountability is very important. We recognise that there is an automatic lessening of accountability in moving from an authority that has some external features to a regional office of government. We recognise that that implies a loss of accountability, and we must establish how that accountability will be made good in the arrangements under the new plan.

Financial accountability is also very important. Projected expenditure savings have been made. However, my interpretation of the answer given by the Under-Secretary of State, the hon. Member for Bolton, West (Mr. Sackville), on the day of the Committee's last sitting, was incorrect. When I looked back at what he said, I realised that he had been consistent in suggesting that he had projected savings of £150 million which applied to the whole country. However, it is fair to say that the Under-Secretary of State for Wales, the hon. Member for Clwyd, North-West (Mr. Richards), purloined £60 million of that overall amount for Wales, which left £90 million for England.

The Parliamentary Under-Secretary of State for Wales (Mr. Rod Richards) indicated dissent .

Mr. Gunnell: It was said in Committee, and I urge the Under- Secretary to look at the relevant proceedings of the Committee sitting. We are talking about global figures, to which I shall return.

Nevertheless, it is important to note that if savings are projected and Ministers have any confidence in them at all, they will obviously welcome not only the duty to publish accounts but the opportunity to publish them, to demonstrate how right they were in their projections. If they do not publish accounts and are not able to accept new clause 2, it suggests that they are not so confident about their projected figures. I shall return to that point.

The annual report is an extremely valuable feature of the Bill. In response to questions which several hon. Members and I asked in Committee, the Minister said that he intended to make clear at some point where every responsibility of the present regional health authorities would lie in future. He indicated that they could all be dealt with and that all current responsibilities of regional health authorities would go somewhere to a specific responsibility--to a health authority or the regional offices which are being set up or to an even higher responsibility. It is important that that indication is

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