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Baroness Seear: My Lords, I, too, wish to thank the noble Baroness for repeating the Statement. I do not wish to be carping but it seems to me a great pity that we should have to interrupt the debate on probation officers, which is an important subject, in order to turn our minds to another important subject. That surely is not the best way to consider matters which are of cardinal importance to a great many people.

I continue my grumbles by saying that this document was handed to me a few minutes ago. I understand that it was only available then. How one is expected to make any intelligent comments when the information arrives at such short notice, I do not know. This discussion surely could have been postponed until we had longer to think about the matter.

So many questions have already been asked by the noble Baroness, who knows a great deal more about the subject than I do, that I want only to emphasise one or two points. In particular, I should very much like to know and have some reassurance about what is meant by the words in the Statement that,

Does that mean again that once Ministers are satisfied they will tell us what is to happen? Or does it mean that when a further report has been produced we shall be given the information and have an opportunity for a real discussion on the subject? It is not only in this context that we find the Government's understanding of the word "consultation" somewhat confusing, to say the least.

I should also like to ask what is really going to happen. It is tantalising. We are all extremely interested, and those of us who have been patients in some of the hospitals mentioned are particularly interested, to know what exactly will happen in respect of the amalgamation of Guy's and St. Thomas'. Or has that been abandoned? Everyone will be very interested to know. Whenever I go

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to those hospitals I find that people are still confused. The staff are demoralised by the fact that nobody really seems to know what will happen. Is this not an opportunity to give people a clearer view of what is to happen?

Similarly, the Statement indicates that at St. Bartholomew's and the Royal London capital investment will total nearly £240 million. If the hospital is supposed to be running down or is ultimately to be closed, what is that £240 million to be spent on? Or will all the money go to the Royal London? Can the noble Baroness tell us?

Of course I accept, as a Londoner, that in the past certain parts of London have undoubtedly suffered from the inadequacy of primary health care. Nobody will deny that primary health care is the foundation stone of any health service. For example, those of us with experience of trying to look after seriously ill people at home who have wanted help in the night from the medical service have found it almost impossible to obtain the assistance one would hope would be available. If the changes mean that that situation does not arise in the future, most of us will be very grateful. Is that what is intended?

I am afraid that having read the Statement I am still very much in the dark as to what is to happen.

Baroness Cumberlege: My Lords, perhaps I may address the comment of the noble Baroness, Lady Jay, that this is a rare opportunity to debate the London questions. I remember very clearly having a major debate in this House on the health service in London and its future. Indeed, I remember on that occasion the noble Baroness making the very profound remark that nearly everyone who has looked at London's health services agrees with Sir Bernard Tomlinson's general conclusion that some rationalisation and reorganisation should occur. Therefore, we had some modest support from the noble Baroness at that time for major changes in London.

Baroness Jay of Paddington: My Lords, I am sorry to interrupt the noble Baroness. That is a rather strange way to respond to what I said. I did not say that we had not had opportunities to discuss the situation in London. I said that it was useful to be able to look at a health service decision on the day it was taken. Of course I agree with what I said about Professor Tomlinson's report. However, I began my remarks by saying that many other people have reported since Professor Tomlinson. Have the Government taken any notice of those other reports whose conclusions have been somewhat different in making these decisions?

Baroness Cumberlege: My Lords, of course we have listened to other people. Indeed, we have listened to the King's Fund. On 9th March this year Robert Maxwell, secretary of the King's Fund, said:

    "Our own position is that the strategic objectives of current policies are largely correct but that great care is needed with the handling, sequence and pacing of changes".

As I said in the Statement, we have taken account of those comments, and others, in that we have ensured that in relation to Guy's and Bart's we have allowed more time to bring about these major changes so that they occur at a slower pace.

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We have also listened to many other people in addition to Professor Jarman. The noble Baroness will remember that Professor Jarman's concerns were not so much with the loss of acute beds as with the fact that primary care in London was very poor. That is a conclusion with which your Lordships have agreed every time we have discussed the subject. He was also concerned that there were not enough long-term, continuing beds. The health authority of Lambeth, Southwark and Lewisham has already received 650 applications for nursing home beds. Those are to be registered. The London borough of Lambeth is investing in 150 beds for long-term care. Therefore, we are trying to meet the problems that Professor Jarman outlined and are investing quite heavily at Guy's in mental health beds.

We have also listened very carefully to the independent specialty reviews that we ourselves commissioned. Dr. Chris Paine, president of the Royal College of Radiologists, said that he felt that there was a need for fewer, larger specialist centres, most closely linked to general hospitals, and that that would lead to a stronger service and research base than we have now.

In the cardiac review Professor Geoffrey Smith, president of the Society of Cardiothoracic Surgeons, when studying care in London, said that none of London's existing 14 centres provided adult tertiary cardiac services which met the criteria laid down in all respects, and many fell well short.

Service, research and development and teaching considerations all point to the concentration of resources and expertise in fewer, larger centres.

I could go on and mention Mr. Rab Hide, chairman of the neurosciences review, and Professor Sir Norman Browse, president of the Royal College of Surgeons. They were at one in saying that there was a need for services in London to be reorganised to meet the needs of the 21st century.

We are investing very heavily in primary care. Your Lordships have always felt that that was the way forward for London. Over the next three years we shall invest £210 million in over 1,000 primary care projects. Some of those are nearing completion and others are under way. A huge amount of investment is taking place.

The London Implementation Group was always a time-expired body, as recommended by the King's Fund, when the commission produced its report. The major decisions have now been taken. The implementation of those decisions is up to the two regional health authorities and the district health authorities. We rely on our normal management processes and systems in order to do that.

The noble Baroness, Lady Seear, asked about accident and emergency units and consultation. Whenever we make major changes we have to consult. All the proposals before your Lordships in the Statement today have been heavily consulted upon. If there are changes to the accident and emergency departments we shall of course consult further. We have given an undertaking that we will not close any department unless there is alternative provision which is at least as good.

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I think that I have covered most of the points raised. If I have missed some I am very willing to come back to them.

4.28 p.m.

Lord Boyd-Carpenter: My Lords, can my noble friend add a little to what she said about the closure of beds? I understood her to say that closure would not take place until alternative facilities had been provided on an adequate scale. Can she say what is the total number of beds it is intended ultimately to close under these changes?

Secondly, can my noble friend say whether allowance is made in these changes for the fact that the high standard of medical care in London attracts patients from all over the world, particularly from the Middle East? Has due allowance been made for the inflow of patients into London due to the high standards of care which it is appreciated throughout the world are to be found in London?

Baroness Cumberlege: My Lords, yes. As we see medical care change we see increasingly more patients treated on a day case basis. At one time operations for cataracts required 10 days in hospital. As noble Lords are aware, those can now be done on a day case basis.

Regardless of what happened, we would see reductions in beds. We seek to ensure that it is a controlled reduction, that it makes sense, and that there is sufficient investment not only in day treatments but also in community developments to make up the loss.

To be specific, with regard to the Bart's closure, we expect a loss of something like 188 beds. But with regard to the Royal London Hospital and Homerton, we expect more patients to be treated than are at present being treated within the three hospitals. With regard to Guy's and St. Thomas', we expect something like a loss of 263 beds. However, the time has come when we have to consider healthcare not in terms of loss of beds but of patients treated and the quality of care given. We know that many would rather be treated locally by their own GPs if only the primary care were good enough.

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