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6.16 pm

Ms Karen Buck (Regent's Park and Kensington, North): I congratulate the Government on a solid record of achievement in the two years since the election. We have now seen the beginnings of the dismantling of the internal market in the health service, which was so bureaucratic and divisive, set hospital against hospital and created a two-tier service in primary health care. Patients were often treated not on the basis of clinical need, but according to whether they had a GP fundholder.

We now have London's largest ever hospital building programme. The comprehensive spending review has provided not only generosity in investment in the health

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service, but a three-year funding package which provides security--in contrast to the squeeze-and-spurt process that characterised the years of Conservative government, when a generous pre-election investment would be followed by a tight squeeze after the election.

We have more new initiatives, which have already been well described by my hon. Friends. For example, there is the sure start programme, run with the Department for Education and Employment, and NHS Direct. I shall limit my enumeration of the Government's virtues only because time is limited and others wish to speak.

I shall make four points. First, on the subject of health inequalities, I congratulate the right hon. Member for Cities of London and Westminster (Mr. Brooke) on having so eloquently made the case about poverty and deprivation in central London. The Government, too, are to be congratulated on the commissioning and publication of the Acheson report into health inequalities, which laid out an excellent strategy for tackling many of the problems that underpin poor health.

What the Government have done stands in stark contrast to the handling of the Black report, which the right hon. Member for Cities of London and Westminster also mentioned. That was an excellent document which, had it been implemented when it was published, would have prevented many avoidable illnesses and premature deaths. Shamefully, it was suffocated at birth, which was typical of the Conservative Government.

I shall make another point about primary care, which was also mentioned by the right hon. Gentleman. The Opposition spokesman, the hon. Member for Rutland and Melton (Mr. Duncan), talked about single-handed GP practices, which he, unlike the right hon. Gentleman, favoured.

Inner London has a staggeringly high proportion of single-handed practices. Although people naturally want to relate to an individual GP, and know his or her name and face--that can be a problem for group practices--single-handed practices undoubtedly do not provide the same quality of patient care, especially out-of-hours care which is so important. That is definitely one of the factors underpinning the inappropriate use of accident and emergency departments that is a feature of inner-city life.

Excellent models of co-operative working are now being developed in the primary health care sector. In St. Charles hospital, the GP co-operative has done excellent work in bringing together GPs to work co-operatively to provide 24-hour care. GPs working alone or in small practices face a heavy burden in providing out-of-hours care. The Government should be congratulated on elevating primary care to a central role in health care, as exemplified by primary care groups.

I welcome the inclusion of the development plans for St. Mary's, Paddington in the provisional three-year development programme set out in the Government's response to the Turnberg report. The hospital is situated in the constituency of the right hon. Member for Cities of London and Westminster, but I am sure that he will appreciate that it is my local hospital, too. The plans that have been drawn up by St. Mary's for the next phase of development are exciting and positive, providing an opportunity for the reconfiguration of specialist services across west London and fitting in with the exciting Paddington regeneration scheme. I hope that those plans will be considered favourably by the Minister.

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I pay tribute to the leadership of the St. Mary's trust, under the still relatively new trust chairman, Trevor Campbell-Davis, who is an efficient, effective and dynamic leader. He was instrumental in turning around the St. Charles hospital in north Kensington, which was in a poor state a decade ago, but which has changed dramatically and now makes a valuable contribution to the quality of care for north Kensington residents.

I welcome the fact that the Government have published a coherent strategy for mental health care services in their response to Turnberg and in the Green Paper on mental health services. The Government have backed that up, as my right hon. Friend the Secretary of State said, with £37 million extra for health and social services psychiatric provision. How desperately we needed that money. Psychiatric provision--especially acute psychiatric provision--was woefully inadequate by the early 1990s.

One of the most awful features of London health care in the 1980s and 1990s was how often severely mentally ill people spent the night in police cells because there was no secure acute psychiatric accommodation for them. On occasion, people were driven out of the capital, away from whatever support services they needed, to secure psychiatric beds in places such as Chester, Brighton and Southampton. That situation needs to be turned round.

The Turnberg report and the mental health services Green Paper set out a strategy based on investment, improved care processes, an improved legal framework and a recognition of the inadequacy of the past implementation of community care. That strategy is coherent, thoughtful and backed with resources. However, I ask the Minister, who is fully committed to delivering on the issue, to help to ensure that other Departments and local authorities provide essential support for the strategy. The need for a co-ordinated, multi-agency approach to mental health care services remains critical, as highlighted by the recent Dixon inquiry into the murder of PC Mackay by a severely mentally ill man under the care of Kensington, Chelsea and Westminster health authority. It is appropriate at this moment to pay tribute to PC Mackay, and the other police and front-line workers who so frequently put themselves at risk of attack and murder by members of the public who have severe mental health problems.

The Dixon inquiry revealed serious weaknesses in police and management that those authorities--to their credit--have embraced and are beginning to implement. Underpinning all that is the desperate need for an adequate reflection of London's problems in all the funding settlements, some of which were mentioned by the right hon. Member for Cities of London and Westminster when he talked convincingly about the under-enumeration of vulnerable groups.

The incidence of psychiatric morbidity in central London is four times the national average, and schizophrenia is three times more prevalent than nationally. One third of mental health service users in central London either are homeless or have no local connections. As the Acheson report found, 45 per cent. of bed-and-breakfast occupants experience severe psychological distress, compared with 20 per cent. of the general population. As the Dixon inquiry highlighted, there are 183 severely mentally ill people in bed-and-breakfast accommodation in one borough alone. That is untenable, and we must ensure that action is taken to prevent that situation from continuing.

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The social exclusion unit and the rough sleepers unit are doing excellent work, in partnership with Government Departments, in dealing with a lethal cocktail of mental illness, homelessness and substance abuse, after those problems had been neglected for years. However, it is early days: the need is desperate and we must do everything in our power to stop people who are severely mentally ill being put in bed-and-breakfast accommodation.

Social housing to provide care for those people--especially for those who are single--must be fairly distributed across London. We must resist the pressure that has built up over recent years--certainly in Westminster--to create psychiatric ghettos in poor corners of the city. They can only add to a problem that is already serious, both for those who suffer from mental illness and for the wider community. I look forward to my right hon. Friend the Minister's response.

6.26 pm

Mr. Gareth R. Thomas (Harrow, West): I, too, welcome the opportunity to debate London's health service. The reforms in the Health Bill--especially the abolition of fundholding, the replacement of the internal market and the emphasis on quality--are long overdue. The focus on promoting partnership across health care boundaries will also be welcomed by Londoners.

The Conservative Government's stewardship of the national health service in London had, by May 1997, produced waiting lists at record levels and an internal market that fostered competition, inefficiency and chronic under-investment in patient care.

In the very worst cases, the internal market generated a form of bureaucratic imperialism, as a few chief executives of trusts sought to gobble up the activity of neighbouring trusts to bring in new streams of income, often at the expense of quality and ignoring local concerns. The crazy merger of Watford general hospital and Mount Vernon hospital was one such example. They were very different hospitals in terms of their clinical specialties: one looked to help patients in Hertfordshire, the other served people in London.

The merger involved a highly destabilising revolving circle of senior executive staff, and an increasing loss of transparency and local accountability in the trust's finances. Ultimately, it led to the loss of Mount Vernon's status as a district general hospital and the closure of its accident and emergency unit. Those two decisions have had a disastrous consequences for the remaining services on site, as other hon. Members have noted.

Divisive and destabilising competition was the product of the structure that we inherited, but quality must be the motor of the new structure for London's health service. Quality cannot somehow be imposed. We cannot magic it into hospital processes: it is not the concern only of the royal colleges or of those hospitals where poor standards of care have been identified.

A commitment to quality is, first, a state of mind--a determination to do better. Excellence has to be rooted in every aspect of a trust's operations. For example, quality must be the guiding force in every new service change.

The new duty of quality that the Health Bill imposes on London's health providers is, therefore, essential. Effective quality improvement processes must be in place in every hospital. Even where standards are good, we must

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encourage management to ask how they can be improved further. We cannot have the management of even one London hospital looking at events in Bristol or Kent and saying, "They could never happen here, so we can just go on as we are."

In 1995, the National Audit Office first highlighted variations in NHS trusts' commitment to clinical audits, one form of quality control. In May last year, the medical press highlighted the continuing variations in that commitment. So it is clear that there is a need for a comprehensive quality programme to reinforce the new duty. The Commission for Health Improvement, able to monitor local clinical governance issues and the implementation of national health service frameworks across London, and to tackle persistent problems will help to drive forward such a quality programme.

Those measures are coupled with London's share of the £21 billion of new investment, and I praise my right hon. Friend the Secretary of State for providing £780,000 to modernise Northwick Park hospital's accident and emergency unit. All this will help to restore the belief of patients and carers that quality of care, not the financial bottom line, is the true raison d'etre of London's health service.

The merger of Northwick Park hospital with the Central Middlesex is an example of the new rationale. Two acute hospitals will continue their current levels of activity while merging into a single trust to release money from administration for patient care. Crucially, they will also bring together clinical teams to improve services and drive up standards of care.

London's health service has many near neighbours who, at different times, are better positioned to deliver health gain. Securing true partnership with the many arms of local authorities and with other statutory bodies whose primary purposes are, say, crime and disorder or poverty has been the aim of many health care reformers for 20 to 30 years. Only when the Health Bill becomes law will that wish begin to be fulfilled.

Together with the establishment of a Greater London Authority, a London development agency and the creation of a single London NHS region, important new opportunities are opening up for strategic health partnerships across London to tackle the health concerns of Londoners. London needs a health strategy to which the boroughs and other pan-London statutory bodies and stakeholders are committed. I welcome the NHS executive event that is planned soon to begin shaping the vision behind a London health strategy.

In my borough, a new spirit of partnership across the health care divide has begun to flower. Where once local hospital chief executives and council leaders would prowl warily around one another between routine confrontations about each proposed change in health care arrangements, the health White Paper and the granting of pilot status for best value to Harrow council have released wasted energy for more creative and innovative attempts to build genuine partnership, trust and understanding of the constraints and opportunities that confront local service providers and purchasers.

It would be wrong to suggest that everything in Harrow is sweetness and light, or that it will be so when the Health Bill becomes law. There is sustained enthusiasm, but there are questions too. General practitioners who felt ignored by

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the local health authority and hospital managers who felt dragooned into fundholding have reservations about yet more change in their ways of working.

Hospital doctors, used to the destabilising change that was brought year after year by the perversities of the internal market, point to considerable challenges facing the health service. Even the most sceptical are engaging with and being engaged by other health and social care stakeholders, partly through the Harrow partnership, the vehicle for the council's best value pilot. Elections to the primary care group were strongly contested, and the west London NHS Direct bid was enthusiastically supported. Local hospitals are beginning to explore more effective ways of communicating with all GPs.

In Harrow, there is a sense of a service changing for the better, establishing effective partnerships and focusing on how best to allow existing excellence among local NHS and social care staff to develop. London needs more imaginative arrangements for providing and integrating services to raise the quality of care received by patients and their carers who, not surprisingly, are more concerned with totality of service than with whether part of a service is provided by an NHS trust or a local council.

London's health service learned important lessons about integrated care from the way in which winter pressures money had to be used. That money forced a much more rigorous approach to joint working around the discharge and rehabilitation planning for elderly people. We must continue that approach in the health improvement programmes, locking in local providers of London's health and social care to shared and accountable agendas for local health priorities.

When the Health Bill becomes law, the excuse for lack of proper joint working between health service and social services staff in London will be removed. The opportunity to blame legislation, or its interpretation by finance staff, will simply no longer exist.

The Health Bill, London's share of the £21 billion investment and the creation of a Greater London Authority mark the end of a new beginning for London's health service. The challenge will be to maintain the momentum.

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