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Baroness Jay of Paddington: I thank the Minister for that reply. As I said in my opening remarks, I am encouraged by the new guidance which is going out to local health authorities and the new health authorities. I suspect that the basis of my concern is the one which I have raised quite often in discussion with the noble Baroness. It is the question of how one achieves the sort of equity and kind of standards which I am sure that she and her right honourable friend want to see achieved, without any kind of national standards or national criteria for local health authorities to work to.

It is difficult from a ministerial perspective to imagine the difficulties which may be faced by local people working in this very complicated field, and often dealing with very difficult and sometimes rather tragic cases, to be able to rationalise and perhaps even justify to themselves decisions which may seem rather harsh or difficult whether on a medical or a social care basis. It would be helpful if they could have some national criteria and national standards. They could then take comfort from the fact that decisions had been made on the basis of a national policy as a way of establishing continuing standards for the National Health Service.

As I said, I am encouraged by the fact that the Minister is relying on the new guidelines. We shall have to monitor them closely and hope that they work. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 7 not moved.]

Baroness Robson of Kiddington moved Amendment No. 8:

Page 2, line 12, at end insert:

("Strategic Health Planning Authority for London

8A.—(1) It is the duty of the Secretary of State to establish a Strategic Health Planning Authority for the region of London.
(2) It shall be the duty of the Authority established under subsection (1) above to direct activities of the London regional offices of the National Health Service.
(3) The membership of the Authority shall be established in accordance with Part I of Schedule 5 to this Act.
(4) In this section "the region of London" means the area of the London Boroughs.".").

The noble Baroness said: I have pleasure in moving Amendment No. 8, which stands in my name. When introducing the Bill on Second Reading, the Minister said that it put the finishing touches on the present reforms of the National Health Service. Therefore, this is probably our last opportunity to consider the problems

28 Mar 1995 : Column 1553

facing London. I hope that we shall not have any more health service Bills, given that this is supposed to be applying the finishing touches to the present reforms.

I believe that we must look at the problems of London specifically. As Members of the Committee know, I was chairman of one of the metropolitan regions covering London in 1974 when the four metropolitan regions were established. Each region covered an enormous outlying area. Indeed, the whole of south-east England was divided between those four regions. We grew up in the period when the effects of the Resource Allocation Working Party (RAWP) began to be applied. That was when the metropolitan regions lost out in terms of resources to regions in other parts of the country which had been doing badly before. That happened because the metropolitan regions were considered to be rich—although they are not really. The outlying areas may be rich, but London is certainly not one of the well endowed regions when it comes to the provision of National Health Service services for its population.

I remember that only a year or two after the introduction of the regional health authorities many of us in those authorities discussed the problems of trying to make sense of health provision in London. We wondered why we could not have one regional health authority to cover greater London. Therefore, what I am proposing now is not a new idea. However, it seems a perfect opportunity to do something about the problem.

None of the various co-ordinating committees in which I participated managed to achieve complete co-ordination of health provision in London. There was always too much sectional interest for success to be achieved. Since then, there have been many reports about the problems of health provision in London, particularly the Tomlinson Report. It is true that London has enormously special problems. It has a great number of teaching hospitals, many postgraduate special health authorities and, along with that, probably some of the poorest and most neglected community services of any region.

If we are to have a coherent health plan for greater London, it is important that we establish an authority which will carry out the proper strategic health planning that is required. I do not believe that that can be done by different authorities. Although we have now abolished the four regions—there are now the two regions of North and South Thames—it is my contention that the only way in which we shall be able to make sense of the health services in London is to have a planning authority for the whole of London. I beg to move.

Lord Rea: I support the noble Baroness, Lady Robson, in her amendment. With her experience as chair of one of the regions which contained both deprived inner, and leafy outer, London boroughs, as well as the affluent communities of Surrey, the noble Baroness is well placed to draw attention to the difficulties of catering for the wide range of needs of such a population. The noble Baroness, Lady Cumberlege, who is to answer for the Government, has precisely the same experience of looking after that region.

If a map is made of the United Kingdom in which health authorities—or electoral districts—are shaded

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from light to dark according to their degree of relative deprivation or poverty, as we all know, the south, especially the south-east, appears white or a very pale shade of grey compared with the north or north-west. The exception however, is inner London. As the noble Baroness pointed out, it stands out as a sizeable dark blot on the map, a blot covering the inner core of the former four Thames regions, now reduced to two.

The concentration of teaching hospitals in inner London, and thus the allocation of National Health Service funds, has historically directed attention away from providing the community services which are needed for relatively deprived people while outer London's hospital services were being built up to decrease the dependence of outer London's population on the relatively expensive teaching hospitals. We know that the Government are now aware of the need to build up primary and community health care in inner London. The squeezing and merging of the teaching hospitals o la Tomlinson has revealed and accentuated the deficiencies, particularly for those with mental illness which is, of course, far more prevalent in deprived areas, and particularly in inner-city communities.

As the noble Baroness pointed out, how much better it would have been if historically the needs of the whole of inner London could have been considered as a unit. In the future, the skeleton of the regions which remain will function better under the overall aegis of the strategic health planning authority which is proposed by the noble Baroness. The London Implementation Zone (LIZ) and the London Implementation Group (LIG) are a precedent. They already straddle the two remaining regions. I suggest that there is need for a continuing, overall co-ordinating body, such as the noble Baroness suggested. I fully support the amendment.

Baroness Gardner of Parkes: I am interested that the noble Baroness, Lady Robson, referred to RAWP because that was when resources started to move out of London under a Labour government who said that London had too much. I do not know whether that was on a financial basis. It is not clear to me whether that was what the noble Baroness was saying. But as the noble Lord, Lord Rea, pointed out, historically there were too many teaching hospitals in the centre of London and, by comparison, other areas were deprived of services—

Baroness Robson of Kiddington: I referred to RAWP because under RAWP all the London metropolitan regions lost money to the regions further out in the north.

Baroness Gardner of Parkes: Exactly. The same has been happening under the London Implementation Group and as a result of the Tomlinson Report. They have continued what started under RAWP. RAWP was the beginning of the change to move funds out of London.

The noble Lord, Lord Rea, talked about inner London whereas, in her amendment, the noble Baroness refers to,

    "the area of the London Boroughs",

which means both inner and outer London.

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There is a marked difference between the old LCC inner London area and the GLC greater London area. To tie the authority to London would be complicated and not necessarily beneficial at this stage. The North Thames and South Thames regions, as the noble Baroness said, encompass much greater areas. To bring back an authority to cover just London—as I say we have discussed whether it would be inner or outer London—would not make it coterminous with anything.

We had a debate earlier about health authorities being coterminous. There is no greater London council, so there is no one authority with which the proposed authority could be coterminous. I do not see the case for allocating an authority just for London. The present mix of the areas outside London with London is right. When I was vice-chairman of my region I found it beneficial to contrast what was happening in the North East Thames Region (inner London) with what was happening in Essex. Of course North Thames now takes in the whole of Hertfordshire as well.

Patients do not recognise boundaries. London also attracts patients from outside London. I do not believe that this is a practical amendment and I oppose it.

6.30 p.m.

Baroness Miller of Hendon: The Government are committed to improving health care in London. That is why we set up the London Implementation Group which has provided the impetus for initiating long overdue changes. Making London Better, which was the Government's response to the Tomlinson Report, sets out clearly the framework for action. It has four main strands: first, to develop better, more accessible primary and community health care services through GPs and other professionals working in the community. I am sure that the noble Baroness, Lady Robson, and the noble Lord, Lord Rea, will be pleased about that because they commented upon primary health care.

The second strand is to provide a better balanced hospital service, meeting the needs of London's resident, working and visiting populations more appropriately; thirdly, to concentrate, develop and enhance specialist healthcare services; and, lastly, to take action for the benefit of teaching and research. But the work of the London Implementation Group is now complete. It was established to take on responsibility for the reorganisation of the city's primary and acute services and its medical education and research. It had a temporary role.

The King's Fund Commission produced an authoritative report on the issue of health care in London in 1992—before the publication of the Tomlinson recommendations. The King's Fund report—London Health Care 2010, changing the future of services in the capital—recommended that a task force like the London Implementation Group should be established. But, it did not recommend establishing a single health authority for London. That possibility was considered and rejected.

London is made up primarily of individual communities, often with a diverse cultural and social make-up. The needs of those communities also vary considerably within local areas. A single strategic health

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planning authority for the whole of London would not take account of that variation. The emphasis must continue to be on local health needs met by local health authorities. I agree with my noble friend Lady Gardner that it would not be helpful to confine "the region of London" to the "area of the London Boroughs". That does not take account of natural population flows, particularly on the margins of greater London. The Thames regions include Kent, Sussex, Essex and Surrey. Those areas need to be considered alongside London.

Individual health authorities will be the key strategic bodies in the new system, acting at local level in London as elsewhere. Where issues affect more than one HA, they will be expected to work together in consortia or by identifying a lead HA. In that way, we can ensure that the needs of local communities will be taken into account. Of course, some oversight at a wider level than that of HAs will be needed. The regional offices of the NHS Executive will oversee the work of the health authorities. They will make sure that HAs work together where appropriate. And there will be only two regional offices for London, replacing the four Thames RHAs which previously shared responsibility for London. The regional offices will be well placed to co-ordinate where necessary.

A strategic health planning authority would serve only to impose another administrative tier. It would mean more bureaucracy, administrators and managers. There would be a real risk of London dominating the rest of the country instead of having a proper balance between the regions. The Bill puts in place the necessary structures for NHS management. There is no reason to treat the capital in a totally different way from the rest of the country. I hope that the noble Baroness, Lady Robson, will withdraw the amendment.

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