§ Question again proposed, That the amendment be made.
§ Mr. Dubs
As I was saying, the lack of conterminosity between local authority boundaries and health services boundaries is more acute in the London area than in other parts of the country. That makes joint planning between health authorities and local authorities more difficult than in most other parts of the United Kingdom. Therefore, in London there are particular difficulties in organising the National Health Service, and there are doubts about whether it is organised to the best advantage of the people of London.
There is much reason to think that a change in the organisational structure of the Health Service would be advantageous to Londoners. I fully accept the view that the present time is never a good time to reorganise ; some other time is always better. But we will be missing an opportunity if we do not take advantage of the Bill and of the consultation process in "Patients First" that will enable us to think again about how the Health Service should operate in London. Paragraph 45 of "Patients First" states :In the light of the major changes in the structure and possibly in the health services in London which it foresees, and of the consequent need for a stable basis on which these changes can be introduced".The consultative document states further that the Government do not contemplate any major changes in the boundaries in the next few years. That is the wrong conclusion if a stable basis for the Health 160 Service is the desired aim. If there is dissatisfaction with the present structure of the Health Service in London, that can hardly be a basis for the further reorganisation of the Health Service. The Royal Commission understood that clearly when it recommended that there should be an inquiry into the organisation of the Health Service in London.
Surely it is implicit that each new district health authority that is envisaged should achieve some balance in the services to be provided within its boundaries. That means a balance between hospital services and primary care services. With the future of the teaching hospitals now in doubt because of the conclusions of the Flowers report and the report of the London Health Planning Consortium, there could be a district health authority in one part of London with no teaching hospital and no district general hospital as a basis for its services, while another district could have one or more teaching hospital within its boundaries.
It is surely clear from those people who have served on the present area health authorities that one powerful teaching hospital can unbalance the pattern of provision even in the present area. That might be more the case in the new districts which presumably will be much smaller than the current area health authorities. It is essential to have a clear idea of the future pattern of teaching hospital provision in London before deciding where to draw the boundaries of the new districts.
I turn now to primary care services. It is a matter of regret that the family practitioner services will not be brought into the new arrangements 161 However, there are ways in which one can ensure a sensible integration of the other services with the hospital service. That can be better done in the context of a service which is better organised than the existing service in London. The Royal Commission report refers to this in paragraph 7.63, which reads :The London RHAs must make additional provision in distributing funds for primary care services to inner city AHAs to ensure that the improvement to services which we recommend is not impeded by lack of finance.There might be the new problem, however, that if the boundaries are not sensibly planned the provision of those primary care services might be made even more difficult.
The structure of the Health Service in London can affect the delivery of services in at least three ways. The first concerns administration, the second resource allocation and the third the nature of the co-operation that is desired between the Health Service and local authorities. I think that it is agreed that the closer the co-operation between them the better, not only for the day-to-day relationships but because the time has come to look at new experiments in health provision and local authority social services provision and the links between the two. Such experiments can work much better if there is at least a semblance of coterminosity because then joint planning methods can work much more smoothly.
The hon. Member for Putney referred to the Westminster hospital. Many of my constituents have contacted me about the future of the hospital which serves people in the part of Wandsworth that I represent. The plight of the Westminster hospital typifies the uncertainty which bedevils the Health Service in London. It is a first-class teaching hospital with a great record of research and service to the local community, but it is now under threat. This threat will surely in itself be damaging to the hospital. The loss of such a hospital would greatly damage the pattern of hospital provision in many parts of inner London.
The uncertainty which affects the Health Service in London covers virtually all the London constituencies. The uncertainty in my constituency affects St. Benedict's hospital, which is now under threat of closure. The workers are 162 staging a sit-in there in protest against the threat posed to the hospital by the area health authority.
Two other hospitals in my constituency are affected by this trouble. The Boling-broke is having to undergo a change of use to take in patients from St. Benedict's. St. James's hospital must have doubts about its long-term future depending on whether it will be absorbed by St. George's, or whether, inview of the Minister's latest consultation document, which favours smaller hospitals, it might have a more secure life.
Then Henderson hospital is threatened with closure. Although it is not located in my constituency, it provides a major part of the health services in my constituency.
If these doubts and uncertainties about hospital provision are typical of the whole of London, the uncertainty affecting Health Service workers, doctors, nurses and others in hospitals throughout the capital must be damaging the quality of the service being provided. The Minister has taken one or two steps towards meeting the demands for an inquiry by saying that he will establish a London advisory group. That is not a happy alternative, and it is not good enough. It is not an open inquiry and we are not sure how it will operate. Indeed, we are not sure what the status of its conclusions will be.
In Committee, the Minister said that so much is known about the Health Service already that there is no need for more information. The snag is that many of the reports about the Health Service in London cover only bits of the service. In particular, there has been a heavy emphasis on teaching and acute services. To my knowledge, there has been no recent report covering other services in London, particularly primary care services. Above all, the relationship between the various services and which pattern of organisation will be best for London has not been covered by any of these reports.
The fact that a great deal may be known already would suggest that an inquiry would not take a long time. Therefore, the Minister's other argument—that he does not want to delay the reorganisation of the Health Service 163 nationally because the London situation would take time to resolve—carries less weight. We are saying not that an inquiry should be lengthy but that an inquiry is necessary and that it ought not to take too long. The Minister cannot have it both ways. He cannot say that there is enough information already and at the same time that an inquiry would take too long to be feasible. I think that a fairly quick inquiry is possible—an inquiry which would encompass the whole range of health services in 164 London, not just the acute and teaching hospital services, but the geriatric and primary care services in the community.
Such an inquiry would help to set the pattern of the Health Service for many years. This is the time to get it right. We failed to get it right at the time to the previous reorganisation. We have an opportunity to get it right this time. I submit that it is absolutely essential for the future of the National Health Service in London that we get the best possible reorganisation in London and that to achieve that aim an inquiry is urgent.
§ Mr. Rees-Davies
No further inquiry of any kind is needed. The main trouble is that there have already been too many inquiries. That goes for the Flowers report and the Royal Commission. If the Minister has an advisory group which he can select with those who advise him, that is the best way to inquire into the National Health Service. There has been too long a delay on the necessary reorganisation to which the Conservative Party was committed at least 18 months ago.
The right hon. Member for Norwich, North (Mr. Ennals) and my hon. Friend the Member for Putney (Mr. Mellor) delivered premature speeches. The right hon. Gentleman's speech was premature because it assumed, first, that the Government were responsible for setting up the Flowers committee—they were not ; it was the right hon. Gentleman himself—and for setting up the consortium, and they were not responsible for that either. Secondly, it assumed that those who were reporting independently outside the House and who had not discussed the matter with us were putting forward ideas that the Government would automatically accept. That is nonsense. There is not an iota of evidence that the Government will accept any of the ideas put forward by either Flowers or anyone else.
§ Mr. Rees-Davies
Not at the moment.
Therefore, it is essential that we should try to get right one or two of the facts.
§ Mr. Rees-Davies
It may be. I shall give way later.
So far as the facts are concerned, there is no indication that the Government intend to adopt any part of those reports. We know, because we have met Annan and his advisers, that we should await a reasonable opportunity for the Government to consider these matters and to give us their concluded view. That period has not yet elapsed.
I speak with a great interest in the preservation of Westminster hospital. I have been treated there more than once. I understand those at the hospital and I 166 know the hospital extremely well. The Westminster medical school is the finest medical school in the London area. That is not disputed. The facts that the right hon. Member for Lewisham, East (Mr. Moyle) presented are undisputable. It is a first class hospital and it is badly needed. It has a first class medical school. It is unthinkable that the Westminster hospital should close.
That is only the beginning of the case. There is a children's hospital that may have to be telescoped into the Westminster hospital. There is an extremely good annexe that may similarly have to be telescoped. There is an assumption that all the beds will remain ordinary NHS beds. That requires investigation. It is true that people from Putney, Kent, Wandsworth and throughout London need the services of the Westminster hospital. It is well known that it services our colleagues in the House.
Any Minister—certainly any Tory Minister—will use the greatest care when considering how the hospital may be saved. It is only right that when a distinguished committee such as Lord Annan's committee makes a report it should receive careful consideration. That committee is trying to put together the medical schools, trying to save and trying to improve. Irrespective of whether one agrees with the committee's report, it deserves careful consideration. The committee was called on to present a report by the previous Labour Government and not by my hon. Friend the Minister for Health. He did not ask it to do it.
The hospital has about 400 beds. That capacity can be reduced by taking in the children's hospital. We are left with 300 beds that we want to keep. At least half of those beds can be maintained for local use. Why should we not recognise that there is a gigantic international demand for the opportunity to come to Britain and to receive—[Interruption.] I ask the hon. Member for Battersea, South (Mr. Dubs) not to laugh. There was the ridiculous notion that we should get rid of pay beds. It was a preposterous monstrosity to seek to destroy them.
Labour Members may not realise this, but Britain has the opportunity to be the greatest international consortium for medicine throughout the world. We must 167 consider the opportunity to provide services in London for not only British people but those from overseas. That means that we need beds, and good beds. We need top specialists.
There has been talk of leukaemia, cardiology and orthopaedics. All of those departments are first class in the Westminster hospital. As I have said, the medical school is first class. We must give the Government a chance to consider all the facts and the way in which the hospital can be saved. I suggest that that can be done by providing for those in London, for those outside London and for those outside Britain.
It is only right that no Government spokesman has expressed a view on Westminster hospital. The Government are giving the issue careful consideration. It is no good trying to jump them. Labour Members have urged the Minister to say tonight what he will do. That is absolutely ridiculous. Why should he say tonight what he wants to do? It does not matter whether that argument comes from Putney or Norwich, North. I am satisfied that we must wait and see what the Government want to do.
It is high time that the House gave up the idea of looking for independent inquiries. What is meant by "independent"? The right hon. Member for Lewisham, East opened the debate in his customary attractive and moderate way. His speech sounded very good. However, what does "an independent inquiry" mean? Does it mean another Annan report? Who are "independent" people?
It is the job of Government to govern. They are not short of advisers, and if they want any more they can have them. I assure the House that, if the Government want more advice, we have advisers on the Select Committee. If we so wish we can look at this matter in the Select Committee. In fact, the right hon. Gentleman suggested that, but I opposed it because it was premature. We are quite happy, in the Select Committee, to look at a problem of this sort if we think that that is right. But it is not right. When my right hon. Friend is ready to tell the House the Government's con- 168 clusions about the future of the Westminster hospital, he will do so.
I am sure that if my right hon. Friend had not been held down by those advising him, he would have told us long ago about the future of the reorganisation, not only in London. We have been held up now for at least nine months in Kent. We know that the whole of the Kent area authority is a complete waste of time. We want district councils. I believe that most Londoners probably want district hospitals. It is not for me to express a view on what London wants, but I believe that there is far too much delay with many inquiries, holding up the work of the Department of Health. Let it get on with its work. Let us wait to hear what it has to say on the matter. But do not let us criticise the Ministry for views expressed exclusively by outsiders who are not even appointed by it and are not asked for any expressions of views.
§ Mr. Frank Dobson (Holborn and St. Pancras, South)
I begin by trying to explain the extent to which boundaries, particularly NHS boundaries in London, are quite inexplicable to ordinary people.
When a member of the Camden and Islington area health authority spoke to me about some rather backward ideas that the authority had at the time for amalgamating as a teaching hospital the University College hospital in Gower Street, and the Whittington hospital in the north of Islington, I suggested that a more logical joint medical school might be an amalgamation of University College hospital and the Middlesex hospital, which was but 200 yards away. The person in question was quite aghast at this thought and pointed out that the Middlesex hospital and UCH were in separate area health authority areas. Then he paused for a second before delivering the crunching blow to my argument, that the two were in different regions as well.
I am convinced that very few people in my constituency, even many of those working in the two hospitals which are close together, are aware that they are in different AHA areas, and, above all, in different Health Service regions. That illustrates the problems which face the 169 Government if we have changes of boundaries within the London area without thorough consideration of and consultation about all the problems and ramifications.
I support the proposal that there should be an independent inquiry into the boundaries in the London area and into the question of whether there should be a regional health authority for the Greater London area as a whole rather than parts of the capital being represented in four separate health authorities which also include large rural areas outside.
I also believe that any inquiry should contemplate the idea of abolishing regional health authorities altogether, because a very good case can be argued that these authorities simply represent another tier of people who are reporting upwards to the DHSS, and acting downwards towards the area health authorities, and whose functions are to liaise and monitor the relationship between the two. The fewer tiers in any form of government the better. Whatever primary division is finally devised for managing hospitals and health services locally, it would be preferable if there was no intervention between that body and the DHSS centrally. The other tiers simply multiply the amount of paper, with no great advantage. An appointed regional health authority has nothing more to contribute to the allocation of regional resources than a group of appointees or civil servants at the DHSS.
I regret bitterly the RAWP policy that started shifting resources from London. It was introduced by my right hon. Friend the Member for Norwich, North (Mr. Ennals), who has disappeared from the Chamber after his strenuous defence of the Westminster hospital, whose future was prejudiced by the policy that he helped to promote. We all welcome those who have seen the light on the road to Damascus, but we were practically within the city walls before my right hon. Friend recognised the error of his ways.
RAWP has damaged, and, if it continues, will in future damage, health provision in the London area. However, I doubt whether other areas are benefiting as a consequence. The money that the London area appears to be saving never shows up in Trent, Wessex or elsewhere. I am told that, if it does, it tends to 170 appear about three weeks before the end of the financial year, when it is virtually impossible to spend it. RAWP is damaging the Health Service in the London area, and providing precious little resources for improving it outside.
§ Mr. Orme
My hon. Friend has caused several Conservative Members to laugh and agree with him. Perhaps he would address himself to the fact that it is not RAWP that is damaging the London health service but this Government's policies, not least VAT increases, which have seriously affected Lambeth, Lewisham and Southwark.
§ Mr. Dobson
It seems that I shall fall out with my Front Bench tonight. I accept the truth of what my right hon. Friend says about the effects of this Government's policies, but those effects are superimposed on the damage that RAWP was wreaking on the Health Service in London. That is undeniable.
§ Mr. Andrew F. Bennett
My hon. Friend claims that RAWP is causing damage, but can he justify a system where some parts of London were having twice as much spent on them as some regions, although the health profile of the people in some of those regions was twice as bad? Whatever my hon. Friend says about the outcome of RAWP, surely he agrees that the idea was good. Our concern should be that it has not been carried out effectively, and in some regions, such as the North-West, we have not seen the benefits.
§ Mr. Dobson
Anyone with a sense of social justice welcomes the concept of equalising health provision throughout the country. Areas outside London are desperately short of Health Service resources because they have been grotesquely neglected by the nation over the years. However, I discern a levelling down rather than a levelling up as a result of RAWP. It has started to damage the Health Service in the London area, with no discernible benefit outside.
We need to improve the standard of the Health Service in London. If any hon. Member believes that the London hospitals or the provision of GPs in London are satisfactory, they should ask the people of London. They think that they are unsatisfactory, and so do I. We need to 171 improve the provision, both in London and outside.
There is a mini RAWP—in effect, a regional RAWP. Its concept is to move the big units of hospital provision out of central London to the periphery of London or outside the capital. I agree with my right hon. Friend the Member for Lewisham, East (Mr. Moyle) that for most people in the South-East, and especially those who depend on public transport, the best place for hospitals is central London. It is much easier to get to central London from anywhere in the South-East than to get from one part of outer London to another 20 miles away. Anyone who fails to recognise that is barmy. Into that category comes the North-East Thames regional health authority, which goes along with that policy, and anyone who has been involved with RAWP.
The shifting of hospitals occurred before RAWP came into being. The move of the Charing Cross hospital to Fulham and of the Royal Free from Gray's Inn Road to Hampstead were products not of RAWP, but of the same line of thought. It could be argued that there have been gains from the building of a new Royal Free in Hampstead. There would also be gains if something were done with the old Royal Free site and the buildings on it, but it is salutary to bear in mind that if we are to close hospitals and build new ones elsewhere the NHS needs to be much better in dealing with the buildings and resources left behind than it has been with the Royal Free.
§ Mr. Mellor
I agree with everything that the hon. Gentleman said about London. Does he agree that another unfortunate effect is that we have a major investment in a hospital that has been transplanted, such as St. George's at Tooting, and the bizarre situation that at the same time as £16 million is to be spent on phase two of St. George's, long-established hospitals in the neighbourhood are having to be closed and the provision of many aspects of health care for hospitals further out is threatened by the cuckoo in the nest?
§ Mr. Dobson
I accept that point, but it is separate from the one that I was trying to make.
172 The buildings of the old Royal Free are old by any standards. The frontage was built as a cavalry barracks, so the Royal Free was not born with a silver spoon in its mouth. Next to those old buildings, and formerly incorporated in the Royal Free, is the Eastman dental hospital, which has a world-wide reputation and is one of the premier bodies for research, advancement and improvement in dental provision in this country.
The region, the area or the DHSS is refusing to allow the dental hospital, which is desperately short of space and does not meet some of the provisions of health and safety at work legislation, to make even temporary use of empty space in the old Royal Free buildings. I understand that part of the reason is that the area or the region would like to use the premises as offices. They would be better used by the dental hospital than by the burgeoning administration of the NHS.
The Flowers report has some merit, besides having a pale pink, Roy Jenkins-coloured cover. It is easy to read. Also, possibly like Roy Jenkins, it has no arguments in favour of the conclusions that it suggests. It is based on the concept that big is beautiful, that tidiness is all and that symmetry is wonderful. It is geared to establishing large unit medical schools and to dragging into these major medical establishments anything that is out of the way, novel or different. The object is to coalesce them and bring them under further control.
I cannot believe that any of the distinguished people who were involved in preparing the Flowers report have noticed what happened throughout England, Wales and Scotland as a result of the gar-gantuanism that was the object of local government reorganisation, the Josephite reorganisation of the Health Service—from which the Bill is an attempted recovery measure—and the reorganisation and increased size of water authorities.
The London Health Planning Consortium document—the green document—has demerits. It is not easy to read. Its arguments, if they exist, are difficult to follow because of the amazing prolixity in which everything is described and the complication of the arguments. It is a manifestation of regional RAWP. It is 173 committed to the shifting of resources from the centre and concentrating matters so that everything that is not symmetrical, usual and standard is eliminated as quickly as possible.
Boundaries are a problem, especially in cities. They are probably a bigger problem in London than anywhere else. The size of London demands that the Greater London area should be broken up if it is to be controlled and administered. Most other cities can be administered as a unit, but such a situation does not apply in London. The NHS boundaries are artificial. I should like to demonstrate the effects of the proposals of Flowers and the London Health Planning Consortium on the boundaries that impinge on the area that I represent, which includes University College hospital.
The Flowers proposals, ignoring hospitals such as Great Ormond Street and others, would mean an amalgamation of the medical schools of the Middlesex hospital, University College hospital and the Royal Free hospital. The Middlesex hospital is in the City of Westminster. It is within the Kensington, Chelsea and Westminster area health authority. It is also covered by the Kensington, Chelsea and Westminster family practitioner committee. It is located in the Soho and Marylebone district of that area. It is also in the North-West Thames regional health authority area.
University College hospital, on the other hand, is in the London borough of Camden. It is in the Camden and Islington area health authority, the Camden and Islington FPC area and the South Camden district. The Royal Free hospital is in Camden, within the Camden and Islington area health authority and the North Camden district. Both those teaching hospitals are in the North-East Thames regional health authority area.
The London Health Planning Consortium proposals are to unite the Middlesex and University College hospitals—I shall not bore hon. Members out of their minds by repeating the authorities that are involved—and to unite and bring about a close link of the united Middlesex and University College hospitals with the Whittington hospital, which is situated in the borough of Islington, the Camden 174 and Islington area health authority area and the Islington district of that area.
If there is to be that unification and the Government persist in the idea that districts in London should be formed round district hospitals, where on earth is a sensible boundary? Will it include part of Westminster, part of Camden and part of Islington? I do not believe that a sensible boundary can be formulated by the people at the DHSS, particularly when we consider the boundaries that were formed last time. Anybody who saw that horse fall at the first hurdle will not put any money on it in future.
We need a thorough inquiry into the London area and its NHS boundaries. We must also have thorough consultation with the people who work in the hospital services and the people who hope to benefit from them.
§ Mr. Rees-Davies
If there is an inquiry, the hon. Gentleman will not agree with it and he will make the same speech again. Perhaps he should trust the Minister to set the boundaries rather than the DHSS.
§ Mr. Dobson
Certainly not. I was returned to Parliament not to trust any Minister.
We are not talking about a National Health Service boundary. If the system is to work properly, there must be links with the social services provided by the local social services provided by the local authorities. The links between the social services and the hospitals and doctors are poor enough. If we disturb the boundaries and involve district authority staff in dealing with two local authorities and local authority staff in dealing with two hospitals in the same area, there will be increasing complexity. Many of the NHS staff in the South Camden district do not relish dealing with the Camden social services department—which is well funded, although it has its shortcomings—and with the Westminster social services department, which is organised in a different way and relatively poorly funded. I cannot believe that such matters will be taken into account by the Minister and his distinguished advisers.
Unlike many of my right hon. and hon. Friends, I believe that the London teaching hospitals should be taken out of the district area system in London. I say that not because I want to give them 175 greater privileges but for historic reasons and because they provide both a national and regional service. They so dominate the Health Service areas in which they are located—and will dominate them more if the areas are smaller—that they are better taken out of the system.
It was altogether daft and rather idealistic, if I may attach that word to the right hon. Member for Leeds, North-East (Sir K. Joseph), ever to consider that these major teaching hospitals, with their power, influence and reputation would not dominate the areas in which they were located. I would say, therefore, that we should take them out of the districts. They should, once more, be dealt with directly by the DHSS. The areas and districts would then deal with the rest.
There will be many dissenters from that view among my right hon. and hon. Friends, but I say to them that if they do not agree with my views I do not want to hear them complaining in future that these major hospitals are distorting the provision of service in the areas they represent. That is the argument all along. If those teaching institutions are distorting the service, the answer is to get them right out of it.
§ Mr. Percy Grieve (Solihull)
I have listened with great attention to what the hon. Gentleman has said and I am in complete agreement with the view that the right treatment for the great teaching hospitals is that they should have a special place in the Health Service and be taken out of their districts. One other reason why that should be done is that each of them has, in its way, developed its own specialties which are of national importance.
§ Mr. Dobson
To some extent I agree with the hon. and learned Member for Solihull (Mr. Grieve). I believe that the teaching hospitals have a special position in the Health Service and that the problem has been that we have failed to recognise that special position. I believe that those hospitals would be better controlled and would be more likely to receive a proper share of resources if they were dealt with by the DHSS, which should be big enough to deal with them in the sense of keeping them in order in a way that the area health authorities can- 176 not do. District authorities will be even less capable of dealing with the teaching hospitals.
§ Mr. Dubs
Would not my hon. Friend agree that before the teaching hospitals were the responsibility of area health authorities—before the last reorganisation—they were not being kept in order by the DHSS or the Ministry of Health? Will my hon. Friend comment on this problem? If the teaching hospitals are kept apart from the main Health Service how can services be planned in areas where teaching hospitals exist and how can those hospitals be made responsive to the needs of local communities?
§ Mr. Dobson
I agree with my hon. Friend generally, but I do not agree with him in this case, because I find it difficult to discern that there has been an improvement in the responsiveness of the teaching hospitals to the needs of the people in their localities since the previous reorganisation. I also believe that if the area or district authorities were to continue in existence and dealt with the DHSS and with the major teaching hospitals through a separate process of indicating what was needed for their areas, it would be a clearer process for ensuring that those hospitals dealt with the problems of the areas. The system is wholly confused at present and I think that the teaching hospitals dominate the proceedings of the areas that they serve.
I guess that I am not exactly carrying many of my hon. Friends with me in this argument.
§ Mr. Haynes
Does my hon. Friend also agree that the teaching units pull a fair amount of resources from their areas? That means that the other districts in those areas suffer financially as a result. May I go on to say something else to my hon. Friend? When he was talking about special privilege from the DHSS, I hope he did not mean special privileges in the financial way, for that would mean pulling finance away from the districts, which so desperately need it.
§ 11 pm
§ Mr. Dobson
I agree with the latter point made by my hon. Friend.
I also believe very strongly that the funds going into those areas which have a major teaching hospital—or even two major teaching hospitals—do not reflect 177 the national and regional contribution which those hospitals are making. Consequently, because the national and regional contribution is something that the hospital will not reduce, the people who suffer are those who are dependent on the hospital providing a service in the immediate locality. If we were to take the amount of direct funding which it could get from the DHSS if it were responsible for them, together with the funding of the area without them, we would find that the total would be greater than it is under the present sloppy and confused system.
In my constituency there is a hospital with what is called—it is a term of art—a preserved board of governors. I refer to the Great Ormond Street hospital for sick children. To a limited extent, it provides a service in the locality, but it provides much more than that ; it provides a regional and a national service. It is the place of last referral for desperately sick children.
It was decided—I think wisely—that the hospital for sick children should have a preserved board of governors, should be directly funded by the DHSS, and should not be run by the area health authority nor place any demands on the funds of the area health authority. Both the area and the hospital have benefited from that arrangement. If we consider the effectiveness of that hospital in its hospital provision and in its great specialisation, we have to recognise that the major teaching hospitals have similar important nationwide specialisations. Those specialisations should, therefore, be directly funded by the DHSS. Those hospitals would in consequence, be best taken out of the system.
The right hon. Member for Leeds, North-East has a great deal to answer for in regard to the state that the Service has got into since his benighted reorganisation of it. We need change in London. The present system in London is not acceptable and change needs to be brought about. One of the problems of this change, and the demand for it, is that for years to come it will divert effort from providing a proper health service in London, because the attention of administrators, doctors, nurses, trade unions, people on community health councils, and so on, will be concentrated on the fairly unproductive question of how we establish a hospital and NHS structure in London 178 to put right the wrongs that the right hon. Member did to the London area when he was Secretary of State.
That is sad, because there are enough problems in London already. There is a gross lack of resources in the London area, although some of my colleagues may not agree. There is the low pay, winch has a particular impact in the London area, where the comparative pay of nurses and ancillary staff is worse than it is in other areas because the London weighting does not to any extent compensate for the excess cost of being in London. Consequently, there is a considerable shortage of satisfactory staff at many London hospitals.
An additional reason—I am sure that this will not commend the rest of my speech to those Conservative Members who have seemed to like some of it up to now—why there are problems in the Health Service in the London area is the enhanced and growing and wholly harmful impact of the development of private medical services in the London area. The Wellington hospital and others—which if the Minister has his way will spread—are like leeches on the provision of health services in the London area. They take doctors, nurses and ancillary staff, who have been trained in the public Health Service, away from that Service in the London area. Now we have an amazing outfit called "Medicover", which has moved into the GP sphere. While I agreed with every word he said, I noted the irony of the attack on "Medicover" by a representative of the BMA. Apparently, if someone starts providing a service at GP or house visiting level, which is basically equivalent to the Wellington hospital, it is to be denounced. I am glad that the BMA takes that view about "Medicover", and I hope that it and the Minister will go out of their way to get rid of it.
Any change in the structure—and structural change needs to be brought about—must bring about clear and sensible boundaries, involve large numbers of people in consultation and produce a considerable improvement in both the democratic control of the Health Service in London, because there is none at present other than that exercised through the Minister, and worker participation in the Health Service decisionmaking processes. Possibly I do not 179 agree with my hon. Friend the Member for Wood Green (Mr. Race), who would like workers' control of the hospital service. I believe that the hospital service would be better off if it were controlled by some sort of agreed structure between patients and potential patients and those working in the industry.
§ Mr. Race
My hon. Friend has just denounced the view which he thinks I hold. He may be interested to learn that, along with my union, I favour democratic control of health authorities through direct elections from members of the public—in the same way as we encourage them to vote in local elections—and a measure of worker control through the election of representatives through their trade unions.
§ Mr. Dobson
I can happily say that my hon. Friend and I are at one on this issue.
Apart from the question of the change in organisation, we cannot get away from the fact that the Health Service in London is not in a good state. It is in a bad state. To discover that, one only has to look around the hospitals in inner London and to see the decayed state of many of the buildings, the loss of morale among staff and all the problems which the hospital service faces.
We must ensure that we provide sufficient financial resources and a decent structure which will properly release the skill and dedication of all the staff in the hospital medical services so that they can devote themselves to looking after patients—some of them preventing people from becoming patients—and so that we get a better Health Service. The only way in which we can do so is to ensure that those involved are committed and have the resources to do the job which they have decided to take on. We have let them down for far too long. It is up to the Minister to make sure that they get the resources, but I doubt whether he will, and it is up to us to ensure that they get the right structure.
§ Dr. Vaughan
In view of the long and thoughtful speech of the hon. Member for Holbom and St. Paneras, South (Mr. Dobson), this is clearly an important part of our debate on the Bill.
180 The right hon. Member for Norwich, North (Mr. Ennals)—I am sorry not to see him here at present—and my hon. Friend the Member for Putney (Mr. Mellor) spoke eloquently about the Westminster hospital and the medical school. Other hon. Members also touched on that subject. I am glad that my hon. Friend the Member for the City of London and Westminster, South (Mr. Brooke) is present in the Chamber—he has been present throughout the debate as a Government Whip—because I know of his deep concern for Westminster hospital.
I do not believe that there should be confusion about the future of Westminster hospital at this stage. The Flowers report emanates from a University of London working party, and the report of the London Health Planning Consortium is also the report of a working party. Both are working parties, and their views are not in any way the Government's views. I must make that clear. My hon. and learned Friend the Member for Thanet, West (Mr. Rees-Davies) was right to have said that. We expect proper consultations to take place before any of the recommendations of those working parties are put into effect.
I must also make clear that no decisions have been taken on the future of Westminster hospital, or on any of the other recommendations of those working parties. I care very deeply for the Westminster hospital, and I would not wish the hospital to cease to be a centre of excellence, as my hon. and learned Friend suggested it might. I do not wish it to be damaged by uncertainty, and that is why we must decide urgently what is to happen. We consider that it is important to have a proper advisory group to advise the Government on the various changes that are needed in London.
The Royal Commission recommended yet another inquiry on London. We thought about that carefully, and we reached the conclusion that there had already been a number of inquiries and that yet another would not serve any useful purpose.
§ Dr. Vaughan
No, not at the moment. The right hon. Gentleman asked a number of questions which I shall try to answer.
181 We believe that a body is needed that will pull together the various reports that are available. The only area in which there is a lack of information is that of primary care, and that is why we set up the Acheson inquiry. For the general future of London we have set up a London advisory group under the chairmanship of Sir John Habakkuk, and I have asked him to give priority to advising the Government on the restructuring of the Health Service for London, and the pattern of acute and specialist hospital services in the light of the report of the London Health Planning Consortium and the other reports that are available.
It is not expected that the group will collect any further evidence, but it can do so if it wishes. We feel that enough evidence is already available to enable it to reach proper conclusions. It is important that the group should concentrate on these issues urgently if the restructuring in London is to keep pace with the rest of the country. It would be a tragedy if the rest of the country moved ahead and London was left behind.
I had a meeting last week with the chairman of the London advisory group. The group has already met twice, and it expects to meet again on 23 June, 7 July and to have an all-day meeting on 4 August to consider the University of London proposals based on the Flowers working party—which should then be available. It then proposes to meet weekly throughout September and October. It is doing this in order to be able to advise the Government as quickly as possible.
I have also discussed the functions of the group carefully with the chairman, and I shall answer the questions put to me by the right hon. Member for Lewisham, East (Mr. Moyle) as briefly as possible.
The right hon. Gentleman asked whether the Flowers report, the London Health Planning Consortium report and Professor Acheson's report would be available to the advisory group. The answer is "Yes", although the Acheson report will not be ready before the end of the year. He then asked whether the group would be able to give full consideration to the GLC proposal that there should be a single health authority for London. The answer is "No, not at first." 182 We do not think that that is within the immediate remit of the advisory group. But it would be open to it to do that, if necessary, early next year. It has no plans to do so at the moment, however.
The right hon. Gentleman asked whether it would hear evidence from members of the public and invite bodies concerned in the Health Service to give evidence. The answer is "No." The group thinks, as we think, that the information is already available in the various reports. But it will be making its report public so that when it gives its advice to the Government it will be published.
The right hon. Gentleman asked whether it would be free to consider the future of the postgraduate institutes. The management of these postgraduate centres is a matter for the Government. The linking of the post-graduate centres with the other services in London is very much a matter for the London advisory group. The two will go together so that both that question and that about whether it will be free to look at the teaching hospitals in London receive a slightly guarded answer. If the university puts forward, as we think it may, a number of alternative recommendations in one or two parts of London, the London advisory group will take the various alternatives on board and will come to the Government with clear advice. We think that to be a sensible way of setting about it.
The right hon. Gentleman asked whether it would be possible for the group to consider RAWP. The answer is "No" in the general sense. That does not come within its remit. But the financial implications of regional RAWP might well enter its consideration because that might well apply to individual hospitals which it is examining.
The right hon. Gentleman asked whether all these matters would be considered and recommendations made by the group before there was action on them in general terms. The answer is that the recommendations from the group and the reasons for them will be given as advice to my right hon. Friend the Secretary of State. They will be published so that they can be discussed publicly, if necessary, before the Government take action on them. The right hon. Gentleman asked in a footnote whether the 183 group would consider the future of the London ambulance service. The answer is "No". That is not within the group's remit.
I have gone through those questions rather rapidly because it is late and there are many other aspects which I know hon. Members wish to discuss on other parts of the Bill.
§ Mr. Race
For me the night is young, Mr. Deputy Speaker.
My points on the amendment are related to what the Minister has just said. It is extraordinary that the group will look at some aspects of the Health Service in London but not at others, and will have removed from its consideration any method of approach which would create one regional health authority group for London. It is impossible to fix the level of resources to be pumped into London without knowing in advance how many regional health authorities, district health authorities and district general hospitals there will be within that area.
To have the advisory group not look at the prospect of having one regional health authority for London is extraordinary. To have the advisory group not look at the London ambulance service is also extraordinary. The London ambulance service has a severe crisis on its hands. First, it cannot recruit manpower in competition with the other emergency services—the police and fire services—because its pay levels are far below those two services and, secondly, it cannot get to a high proportion of its emergency calls within the limits which have been set by the DHSS. Therefore, for the Minister to reject the view that the advisory group or an inquiry should look at the London ambulance service again seems extraordinary.
London is the only part of the country which has this sectoral approach. It is the only major city in the country which has four regional health authorities operating within it. My hon. Friend the Member for Holborn and St. Paneras, South (Mr. Dobson) made this point clearly, and I shall not go over it at any length. However, it is absurd to have four regional health authorities with disparate internal distributions of population and social composition trying to administer and deliver health care within that region, 184 especially when there is no machinery for looking at the problems of London as a whole other than through the London Health Planning Consortium.
I found it amusing when the hon. and learned Member for Thanet, West (Mr. Rees-Davies) suggested that the. London Health Planning Consortium was not connected with the Government. Of course it is connected with the Government. It has a direct link with the Government. It was by direct Government encouragement that the consortium was set up. No one is complaining about that. But to suggest that the Government are not committed to the concepts which have been discussed by the consortium is absurd.
I refer the Minister to the report on acute hospital services in London which was published last autumn. It points up the problems in London. In the consortium's conclusions at pages 30 and 31 there is a clear analysis of the problems facing the London Health Service. It makes clear that all the talk about internal RAWP, the development of RAWP on a national basis and the distribution of Health Service resources in London as a whole is an acceptable front for the determination of health care policy on the basis of available financial resources. It is important to get this on the record. The report states :As well as the pressure of population movements, the pressure of resources makes change essential. Even if the rate of growth of resources to the NHS increases substantially in the future, moves to level up resource provision throughout the country and to provide equality of access to services will mean that growth within the Thames Regions is less. If the NHS is to improve the services which, particularly in London, are poorly provided—services in the community and for the elderly, the mentally ill and the mentally handicapped—it will have to look to a relative decline in expenditure on acute services.That is why the consortium proposes that between 1977 and 1988 about 6,100 acute hospital beds will disappear from the regional health authority areas in London, primarily to enable other aspects of the NHS in London, which it is accepted are under-funded, to have the opportunity of obtaining additional finance. No one has suggested in the report that the patients that fill the acute beds will require operations any the less in 1988 than in 1977. Indeed, the reverse is true. The morbidity prospects for some 185 sections of the population in 1988 will be worse than they were in 1977. If the Government's public expenditure cuts continue rolling until 1988, it is clear that many will face urgent need for acute medical services. The need will arise because of the cuts that have been imposed by local authorities and other sections of the Service.
The consortium makes it even clearer. It states :The combined effects of increasing throughput"—that is on beds—and the inexorable advance of medical technology and techniques will tend to increase the average cost of using each acute bed ; but if the numbers of beds are not sufficiently reduced, it will be impossible both to pay for improved standards of care outside the acute sector and to allow room for medical development within the acute services.That says it in a nutshell. If doctors are to provide high-technology medical cover, the number of patients in acute beds has to be reduced so that the NHS can provide facilities that are not now available for geriatrics, psycho-geriatrics and others.
The consortium documents explain to Londoners "We are prepared to provide a certain level of maximum care for a certain number of your population. We accept that there will be others who will be in pain and suffering and in need of operations. We are sorry but those operations cannot be carried out because there is not the money to make them available to you." It is absurd for any hon. Member to suggest that there is a measure of equalisation.
I support the view that there should be a levelling up of health care resources in the NHS. No one in his right mind would question that. As a London Member, I must defend the interests of those who go into hospital for operations and who will not have the opportunity of getting those operations after 1988 if the consortium's proposals are implemented. For that reason alone, there is justification for a wide-ranging public inquiry into the problems of the NHS in London.
There are other reasons for advancing this proposal. There are disputes taking place about the provision of accident and emergency facilities in the capital. The Minister will be relieved to know that I shall not refer to the Prince of Wales hospital. However, the hon. Gentleman 186 visited the Royal Northern hospital recently and inspected the accident and emergency facilities. He is aware of the arguments that are advanced by Members and community health councils in London. There is a genuinely held view about the sort of accident and emergency facilities that are required throughout the capital. It would be monstrous if the structural changes that may be proposed as a consequence of the advisory group's reports did not take into account the views of the community on accident and emergency facilities.
Another major justification for the provision of a public inquiry and the publication of its findings is the increasing shortage of nurses in London. At the Whipps Cross hospital, just across the boundary of my constituency and in Walthamstow, 90 beds have ceased to be available because of the failure to recruit adequate numbers of nursing staff.
There were stories in the Daily Mirror and other papers today about the scandalous way in which the Government were treating student and other nurses at the bottom of the pay scale. If the 14 per cent. rate of pay is imposed by the Government on nurses and midwives in the capital, it will mean that fewer nurses will be recruited to train in the London teaching hospitals, and in the other hospitals in London, and inevitably the pressure on acute and non-acute beds will increase, because the numbers of nurses available to man those beds will be reduced quite dramatically.
The problem of bringing nursing staff into the NHS in London is one that the Government ought to consider very carefully. We have had crises of this kind before in the London NHS. We had a manpower crisis in 1973–74, which was resolved only by the imposition of the Halsbury findings for nurses and mid-wives, and by the imposition of increases linked to the cost of living for ancillary staff and other groups in the Service. It is therefore absurd for the Minister to say that these questions should not be dealt with by the advisory group.
There is one other important reason that one can advance for saying why that inquiry should be established, and that is that in the inner London area, certainly in my constituency, the number of extended families is relatively small. The 187 family support that exists for people who have to go into hospital, or who might otherwise be treated in the community, is diminishing all the time. Therefore, the importance of NHS beds in London is such that we ought to have a large number of such beds to take account of the fact that the provision of family support for patients is perhaps lower than it is in rural or suburban areas. That is another reason for special consideration being given to the problems of the London area.
The last major point that I want to make on this question is one that was made in the Royal Commission's research paper No. 3 by Klein and Buxton, because this goes to the heart of the problem of the London NHS. One of the arguments that has been used by Ministers—both in this Government and in the previous one—is that the London Service had to be kept back so that the Service in other parts of the country could be advanced and money could be increased for that purpose.
The argument that was put forward by Ministers at that time was that RAWP would do that, but—and Klein and Buxton make this clear—theMain thrust of public policy has been to devise a rationing system without making any assumptions as to whether or not the resulting allocations would provide an adequate standard or quantity of service.That attempt is now being made in London, and what the Government are really saying is that a rationing system will operate and that Londoners will have to put up with it. I do not believe that Londoners will put up with it. The number of acute beds will drop substantially, the number of accident departments will fall dramatically, the number of nursing staff recruited to the Service will fall dramatically, industrial disputes will be magnified, the community health councils and the other representative organisations in London will not be consulted by the advisory group on reorganisation, the boundaries of the regional health authority will not be discussed by the advisory group and the London ambulance service will not be looked at by the advisory group.
For all those reasons, I believe that what we are getting from the Government is not a comprehensive look at the 188 kind of Health Service that Londoners need. It is a ramshackle attempt to impose a speedy solution at a time when an in-depth inquiry is required. I therefore support the amendment, and I am sure that many of my hon. Friends will join me in doing so.
§ Mr. Moyle
Perhaps it would help the House if I were to intervene at this stage, because the Minister for Health has spoken. I wish to make three points in reply to the debate.
The hon. Member for Putney (Mr. Mellor) spoke about a sense of disturbing impotence in considering the problem of Westminster hospital and the London teaching hospitals generally. I believe from the way things have been arranged, that this is deliberate, because the effective decisions about acute hospital beds in London are being placed on the shoulders of London university, which is not answerable to the House, as a result of a firm lead given by the London Health Planning Consortium, which is the Government's creature. However, when the Government talk about the recommendations of the consortium they will be able to say "In any case, the decisions have all been preempted by London university." The sense of disturbing impotence which the hon. Gentleman feels has not arisen by accident. I believe that it is a deliberate plan.
The hon. and learned Member for Thanet, West (Mr. Rees-Davies) and the Minister said that there had been too many inquiries into the situation in London. I should like to know what they are. I do not believe that there has been any inquiry into the health services in London to date. When the Royal Commission report was published last summer there had certainly not been an inquiry into the health services in London, because the report of the Royal Commission recommended that there should be one. I cannot recall an inquiry into the London health services subsequently. There may have been one or two little pieces of inquiries into little corners of them.
My hon. Friend the Member for Holborn and St. Paneras, South (Mr. Dobson) expressed the view, amongst many other interesting observations, that the resource allocation working party was damaging the National Health Service in 189 London without benefit to the Northwest and Trent. He should take the trouble to go and see new hospitals such as those at Nottingham, Leicester, Rotherham, Barnsley, Chesterfield and in the Trent region and also look at places such as Bassetlaw and Mansfield. He would then see that there is still a substantial need for further action. He might well go to Preston, Salford and Wigan and see the new hospitals going up in the North-West. At the same time he should call in at Oldham and Tame-side and see what else had to be done.
The Minister answered eight of the 13 questions I put to him. He did not answer some of those in the affirmative. The five questions he did not answer were all related to the relationship of the acute hospitals to the social services and community hospitals in London and the relationship of London to the Home Counties.
It is essential that we get clear in our minds what should be and can be the relationship between the London health services and the Home Counties health services and between the London acute services and particularly the social services and to some extent the community services in London. The theory is that the resources of the acute sector should be transferred from that sector in London either to the acute sector in the Home Counties or to the community and social services sectors in London itself. The social services are under considerable pressure. An inquiry must establish that this is a feasible policy, as it has been advocated for some time.
My hon. Friend the Member for Wood Green (Mr. Race) has drawn attention to some of the damage that he believes is being done to some of the acute hospitals in London as a result of these policies. The social services, and the community services in some cases, are under intense pressure in London. It seems to us that, particularly with a reduction of resources rate for London of 0.3 per cent. for this financial year, the source of finance for all these things must be looked at very carefully. There is no prospect at all of this exercise being undertaken under the London advisory group. Therefore, we shall have another piecemeal investigation of yet another 190 aspect or partial aspect of the London Health Service.
I understand that even the proposal of the Conservative-controlled Greater London Council that there should be a regional health authority for the GLC area will not be considered with any degree of urgency by the London advisory group. That is very disappointing because this is a proposal for a different structure for the Health Service in London. I am afraid that what we shall get is another partial exercise in which the co-operation of Londoners will not be asked in the running of their health service.
As a result of what the Minister has said about the activities of the London advisory group and what is planned, there will be continuing considerable discontent in London about the development of the Health Service, whatever Sir John Habakkuk and his colleagues recommend, There will always be a number of people who can point to large gaps in the integrated planning of the London Health Service which has not been properly investigated by any particular body, and that will be a further ground for resisting Government policies. In the circumstances, I can only ask my right hon. and hon. Friends to vote for the amendment.
§ Mr. Clive Soley (Hammersmith, North)
I know that the hour is late, but a number of recent events in my constituency have brought home to me the importance of this amendment. It recognises the importance to London of getting the structure of the National Health Service right. As a result of visits to hospitals and meetings and discussions with various groups in the medical profession, patients and others in the Ealing, Hammersmith and Hounslow AHA, I felt that it was important enough to bring up this matter tonight.
The present management structure in London is causing severe problems. I do not wish to comment in detail on the right structure, but I wish to show the type of problem being caused and to relate it to the amendment, because if it was accepted, it would enable us to tackle the problem effectively.
First, Hammersmith hospital is a very old building. The hospital has an international reputation, particularly in heart 191 surgery. It has the Royal postgraduate medical school there, which will already be fairly hard hit by the Government's proposals for overseas student fees which we debated last week. There has been piecemeal redevelopment over the years, and a planned major redevelopment was postponed in 1974–75. On a couple of occasions the environmental health officer has visited the hospital and has enforced some remedial work which has had to be carried out. That has resulted in considerable expense at a time when RAWP has meant less money in real terms.
I visited the mortuary, the X-ray department and the dining room. The mortuary is unhealthy because the air circulates over the face of the operator. This is also unpleasant. Many thousands of pounds will be needed to put that right. The X-ray department is in an appalling state, with public records being kept in the corridors. Recently the dining room floor collapsed so that there is now a large hole which has been there for some months.
If rebuilding could start in 1985, I would guess that the hospital staff would keep the hospital going. However, the North-West Thames region has already decided not to include the 1985 rebuilding scheme, which would need a minimum of £9 million at 1978 figures, in its programme. The money is to be spent on St. Mary's and St. Alban's, which is outside the London area. If the amendment was accepted, and we considered GLC coterminosity, it might be possible to get a more equitable distribution of resources.
The West London obstetrics unit is famous for its high standard of emotional and physical patient care. It developed the Leboyer method of birth and antenatal care. For some time there has been uncertainty about that unit's future, and rumours of closure must be stopped. The management structure seems to inhibit clear and quick decision making, but I do not blame the managers. The structure is inadequate for an effective decision to be made. Again, it might be easier if we had GLC coterminosity. We could at the same time consider the relevant advantages and disadvantages of moving the obstetrics unit to Charing Cross or possibly to Queen Charlotte's hospital. It 192 should certainly be made abundantly clear that this unit must not be closed.
There is an appalling lack of adequate psychiatric services in this area. Patients in North Hammersmith have to go to Springfield hospital, which is dealt with by the Merton, Sutton and Wandsworth area health authority, and Banstead hospital, which comes under the Kensington, Chelsea and Westminster area health authority and which is 13 miles away. It has been suggested that Hammersmith patients are to be excluded from Springfield by the end of this year. St. Bernard's hospital in Middlesex may have to take them for an interim period until Charing Cross hospital is able to do so. Psychiatrists tell me that that is clinically unworkable. If a transfer to Hammersmith hospital is suggested, even more problems would be created for that hospital.
If the amendment was accepted, the position of Henderson hospital, which is of considerable importance to London as a whole, could also be considered.
Finally, community nursing, which is most important, is greatly underfunded and is not given the priority that it should be given. If we had coterminosity, I suspect that we could do something to develop community nursing on a London basis. That is especially important when we consider health visiting and local authority social services.
For those reasons, I support the amendment.
§ Mr. Pavitt
This debate epitomises many of the problems with the Bill. The Government have revealed their thinking in reply to my right hon. Friend the Member for Lewisham, East (Mr. Moyle). We are asking for a comprehensive and complete inquiry into the Health Service in London before a second mess is made of reorganisation. As in 1973–74, the Government are looking to the experts. London advisory agents will be used. Last time it was the McKinsey report. The Conservative Government always want a father figure to give them good advice.
Our case is that the comprehensive nature of the Health Service demands for London, with its population of 7½ million, a broad look at the whole Service, and not only at the Flowers report, the London Health Planning Consortium report 193 and primary care. My right hon. Friend asked many pertinent questions. The Government's replies reveal so many gaps in the remit to the agency advising the Government that there will be either a whitewash or a tinkering with the periphery which will not touch the basic problems.
The Minister may have faith in the experts, but it was the experts who said that the "Titanic" could not sink, that Picasso could not paint, that Somerset Maugham should not write and that the Maginot Line would never be breached. I make no reflection on the distinguished chairman of the committee and his colleagues, but the Government's approach is fundamentally wrong. The answers that they get cannot satisfy the House.
The Minister has said that the report that he receives will be published. But what sort of debate will ensue? Will we have a whole-day debate on London? Will we have before us propositions that we can amend? Will there be a statutory instrument? How will the House decide what is to happen to London?
There are a number of areas in which London is exceptional. Medical care in the capital can be distorted by the fact that in Harley Street we have the biggest magnet in the world for private practice. Certain consequences flow from that. In the London hospitals, there is a predominance of doctors in acute, surgical or other specialties, and the provision for the areas where we need them most, and where there is no extra money to be earned from private practice—in geriatrics, mental care and mental handicap—is distorted. In London, the distortion is greater than anywhere. When one has a magnet for private treatment, the students in medical schools will choose the specialties that pay most.
There is also a distortion of services in my area. The local area health authority has recently given permission for the American Medical Association to build a 99-bed hospital in the area for private patient acute cases. One of my hon. Friends has already raised the difficulties of nursing shortage in certain areas. One of the most important is the trained and qualified theatre nurse. The extension in London of private hospitals dealing with cases for which payment will be made—mainly surgical operations, orthopaedics 194 and so on—results in a drain of specialised nurses who are essential to the NHS.
No mention has been made of dental care, the part of the NHS that affects more people in London than any other. Dental care has changed since 1974, when the school health service became part of the community dental service, which has a wider responsibility than ever. In London, different arrangements are made by the ILEA and by the outer London boroughs. It is difficult to secure dental care in London without going for private treatment. A comprehensive review of that area by the inquiry committee would have been of great value.
We should also consider the age range of family practitioners, particularly in the less prosperous, inner city areas. There is to be almost a new town developed in dockland, but the need for health services there does not come within the purview of the agency that is advising the Minister.
I am grateful to my right hon. Friend the Member for Lewisham, East for drawing attention to the fact that the Flowers report is the property not of the Government but of London university and it could be acted upon irrespective of the House's views.
I am concerned with the specialty of deafness. Work done by the Royal throat, nose and ear hospital in Gray's Inn Road, the Institute of Audiology and the Institute of Otology is under threat, and we should not look only at the reports of the consortium and the Flowers committee and the way in which medical students are to be brought together. One should look at the specialities. What happens about Moorfields eye hospital? There has been mention of the approach to leukaemia at Westminster hospital. The speeches of my right hon. Friend the Member for Norwich, North (Mr. Ennals) and the hon. Member for Putney (Mr. Mellor) should be placed in gold outside Westminster hospital. Both were expositions of the feelings of hon. Members about our local hospital. The same argument can be applied to all hospitals that are threatened.
The comprehensive medical services between the primary care of general practitioners, the community physicians and hospital doctors and their specialties and the developing occupational health 195 services are, part of what the Royal Cora-mission had in mind in asking for a London inquiry.
The most salient point was made by my right hon. Friend the Member for Lewisham, East—and it was confirmed by my hon. Friend the Member for Battersea, South (Mr. Dubs). My right hon. Friend said that the Sherlock Holmes story of the dog that did not bark was applicable. If the Royal Commission, with all its resources, time and the facilities available to it, felt that it could not deal with this problem and that a special public inquiry was required, the case is unanswerable.
§ I regret that the Government intend to have a back-door committee that will advise them. I fear that the Establishment will get together. A comprehensive health service that all Londoners would like to see is unlikely to emerge from the processes upon which the Government are embarked. This will be highly unsatisfactory not only for the patients but all those working for the benefit of the National Health Service in the Greater London area.
§ Question put, That the amendment be made :—
§ The House divided : Ayes 90, Noes 149.197
|Division No. 345]||AYES||[12 midnight|
|Ashton, Joe||George, Bruce||Prescott, John|
|Atkinson, Norman (H'gey, Tott'ham)||Gilbert, Rt Hon Dr John||Race, Reg|
|Benn, Rt Hon Anthony Wedgwood||Ginsburg, David||Richardson, Jo|
|Bennett, Andrew (Stockport N)||Graham, Ted||Roberts, Ernest (Hackney North)|
|Booth, Rt Hon Albert||Hamilton, W. W. (Central Fife)||Robertson, George|
|Bray, Dr Jeremy||Harrison, Rt Hon Walter||Rooker, J. W.|
|Brown, Ronald W. (Hackney S)||Haynes, Frank||Ross, Ernest (Dundee West)|
|Callaghan, Jim (Middleton & P)||Heffer, Eric S.||Rowlands, Ted|
|Campbell-Savours, Dale||Hogg, Norman (E Dunbartonshire)||Sever, John|
|Clark, Dr David (South Shields)||Holland, Stuart (L'belh, Vauxhall)||Silkin, Rt Hon S. C. (Dulwich)|
|Cocks, Rt Hon Michael (Bristol S)||Home Robertson, John||Skinner, Dennis|
|Cohen, Stanley||Hooley, Frank||Snape, Peter|
|Coleman, Donald||Hughes, Robert (Aberdeen North)||Soley, Clive|
|Cowans, Harry||John, Brynmor||Spearing, Nigel|
|Cox, Tom (Wandsworth, Tooting)||Jones, Barry (East Flint)||Spriggs, Leslie|
|Crowther, J. S.||Lamond, James||Stott, Roger|
|Cryer, Bob||Lyon, Alexander (York)||Thomas, Dr Roger (Carmarthen)|
|Cunningham, Dr John (Whitehaven)||McCartney, Hugh||Tinn, James|
|Dalyell, Tam||McKay, Allen (Penistone)||Walker, Rt Hon Harold (Doncaster)|
|Davis, Terry (B'rm'ham, Stechford)||McKelvey, William||Welsh, Michael|
|Dixon, Donald||McNally, Thomas||White, Frank R. (Bury & Radclitfe)|
|Dobson, Frank||Maxton, John||Wilson, Gordon (Dundee East)|
|Dormand, Jack||Maynard, Miss Joan||Winnick, David|
|Douglas, Dick||Mikardo, Ian||Woodall, Alec|
|Dubs, Alfred||Millan, Rt Hon Bruce||Woolmer, Kenneth|
|Eastham, Ken||Mitchell, R. C (Soton, lichen)||Wrigglesworth, Ian|
|Ennals, Rt Hon David||Moyle, Rt Hon Roland||Young, David (Bolton East)|
|Evans, John (Newton)||Orme, Rt Hon Stanley|
|Field, Frank||Palmer, Arthur||TELLERS FOR THE AYES:|
|Flannery, Martin||Pavitt, Laurie||Mr. George Morton and|
|Foster, Derek||Powell, Raymond (Ogmore)||Mr. James Hamilton|
|Fraser, John (Lambeth, Norwood)|
|Alexander, Richard||Carlisle, John (Luton West)||Garel-Jones, Tristan|
|Alton, David||Carlisle, Kenneth (Lincoln)||Greenway, Harry|
|Ancram, Michael||Chapman, Sydney||Grieve, Percy|
|Aspinwall, Jack||Churchill, W. S.||Griffiths, Peter (Portsmouth N)|
|Beaumont-Dark, Anthony||Clark, Hon Alan (Plymouth, Sutton)||Grylls, Michael|
|Beith, A. J.||Clarke, Kenneth (Rushcliffe)||Gummer, John Selwyn|
|Bendall, Vivian||Cockeram, Eric||Hannam, John|
|Benyon, Thomas (Abingdon)||Colvin, Michael||Haselhurst, Alan|
|Berry, Hon Anthony||Cope, John||Hawkins, Paul|
|Best, Keith||Cormack, Patrick||Hawksley, Warren|
|Biggs-Davison, John||Costain, A. P.||Heddle, John|
|Blackburn, John||Cranborne, Viscount||Henderson, Barry|
|Body, Richard||Dean, Paul (North Somerset)||Hogg, Hon Douglas (Grantham)|
|Boscawen, Hon Robert||Dorrell, Stephen||Hooson, Tom|
|Boyson, Dr Rhodes||Dover, Denshore||Howell, Ralph (North Norfolk)|
|Braine, Sir Bernard||Dunn, Robert (Dartford)||Howells, Geraint|
|Bright, Graham||Fairgrieve, Russell||Hunt, David (Wirral)|
|Brinton, Tim||Faith, Mrs Sheila||Hunt, John (Ravensbourne)|
|Brown, Michael (Brigg & Sc'thorpe)||Fenner, Mrs Peggy||Jenkin, Rt Hon Patrick|
|Browne, John (Winchester)||Fisher, Sir Nigel||Jopling, Rt Hon Michael|
|Bulmer, Esmond||Fletcher-Cooke, Charles||Kellett-Bowman, Mrs Elaine|
|Cadbury, Jocelyn||Fookes, Miss Janet||Kershaw, Anthony|
|Kimball, Marcus||Nelson, Anthony||Spicer, Michael (S Worcestershire)|
|Kitson, Sir Timothy||Neubert, Michael||Squire, Robin|
|Knight, Mrs Jill||Newton, Tony||Stanbrook, Ivor|
|Lang, Ian||Normanton, Tom||Stanley, John|
|Lawrence, Ivan||Onslow, Cranley||Stevens, Martin|
|Le Marchant, Spencer||Page, John (Harrow, West)||Stewart, John (East Renfrewshire)|
|Lennox-Boyd, Hon Mark||Page, Rt Hon Sir R. Graham||Stradling Thomas, J.|
|Lester, Jim (Beeston)||Page, Richard (SW Hertfordshire)||Taylor, Teddy (Southend East)|
|Lloyd, Peter (Fareham)||Parris, Matthew||Tebbit, Norman|
|Lyell, Nicholas||Patten, Christopher (Bath)||Temple-Morris, Peter|
|MacGregor, John||Patten, John (Oxford)||Thompson, Donald|
|McNair-Wilson, Michael (Newbury)||Penhaligon, David||Thorne, Nell (Word South)|
|McQuarrie, Albert||Pollock, Alexander||Townend, John (Bridlington)|
|Major, John||Price, David (Eastleigh)||Vaughan, Dr Gerard|
|Marlow, Tony||Proctor, K. Harvey||Viggers, Peter|
|Marten, Nell (Banbury)||Rathbone, Tim||Waddington, David|
|Mather, Carol||Rees-Davies, W. R.||Wakeham, John|
|Maude, Rt Hon Angus||Renton, Tim||Walker, Bill (Perth & E Perthshire)|
|Maxwell-Hyslop, Robin||Rhodes James, Robert||Waller, Gary|
|Mellor, David||Rhys Williams, Sir Brandon||Ward, John|
|Meyer, Sir Anthony||Ridley, Hon Nicholas||Wells, Bowen (Hert'rd & Stev'nage)|
|Mills, lain (Meriden)||Roberts, Michael (Cardiff NW)||Wheeler, John|
|Mitchell, David (Basingstoke)||Ross, Stephen (Isle of Wight)||Wickenden, Keith|
|Montgomery, Fergus||Sainsbury, Hon Timothy||Winterton, Nicholas|
|Morrison, Hon Charles (Devizes)||St. John-Stevas, Rt Hon Norman||Young, Sir George (Acton)|
|Morrison, Hon Peter (City of Chester)||Silvester, Fred|
|Myles, David||Sims, Roger||TELLERS FOR THE NOES:|
|Neale, Gerrard||Speed, Keith||Lord James Douglas-Hamilton and|
|Needham, Richard||Speller, Tony||Mr. Peter Brooke|
§ Question accordingly negatived.
§ Mr. Rooker
I beg to move amendment No. 28, in page 3, line 12, at end add—' (11) Commencing with the financial year beginning in April 1980 and for the next ensuing three financial years it shall be the duty of the Secretary of State to lay a report before Parliament within three months of the end of the financial year to which the report refers setting out the total financial savings made, the total costs incurred and the number of jobs dispensed with as a result of any action taken under this section.'.
§ Mr. Deputy Speaker (Mr. Richard Crawshaw)
With this we may take amendment No. 40, in page 3, line 12, at end add—'(11) Any increase in value-added tax payments by an authority made as a result of additional inter-authority trading due to changes in administration flowing from orders made under this section shall be met from additional monies from the Secretary of State.'.
§ Mr. Rooker
This debate need not take up as much time as the last one provided that the Minister has some answers for us. These are by way of probing amendments, though that does not mean that we shall not push them if we do not get some satisfactory answers.
We wish to give the Minister an opportunity under amendment No. 28 to see whether, two and a half months after the conclusion of the Committee stage, he can be a little more precise about the financial savings that the Government plan to make as a result of the reorganisation under clause 1 of the Bill.
198 In Committee, and beforehand, we heard various estimates that ranged from £19 million, through £30 million to £50 million a year.
I remind the Minister that he made a fairly categorical statement to the Conservative Party conference last year, when he said :In our streamlining we shall save at least £30 million and more—I believe much more—which can then go to the care and treatment of patients.In a fairly prolonged debate in Committee on clause 1, the Minister was unable to tell the Committee—and so far has been unable to tell anyone else—precisely how that £30 million is calculated, other than that it is 10 per cent. of the so-called managerial costs. If that is the basis we want to know how the 10 per cent. of the saving will be obtained.
It may be that, in the period since the Committee stage, the Minister has been doing some homework and can now tell the House precisely what financial savings the Government intend to obtain from the reorganisation. The country and the workers in the Health Service will not thank the Government for going through another reorganisation, with the alleged reason of saving money, if at the end of the day we do not save any money whatever.
§ Amendment No. 40, which is a Back-Bench amendment, is basically to explore the position touched on in Committee about the increased inter-health authority trading that will take place as a result 199 of creating more authorities. In Committee the Minister, in reply to me, said that the question of the extra VAT payments that may be forthcoming was one that the DHSS was discussing with the Treasury, the implication being that there would be a way sought to avoid an extra burden of VAT payments on the NHS as a result of the reorganisation. I do not think anyone intends that as a result of the reorganisation we should be imposing the ludicrous position of the NHS paying more out of its cash-limited finance in VAT simply because of an increase in inter-authority trading.
§ We want to give the Minister an opportunity, of which he was not able to take advantage in Committee, of explaining to the House and the country exactly what financial savings he expects to accrue and how they are made up. Without that, nobody has a yardstick with which to measure what the Government intend to do. Unless we know how those savings are made up, there is no way that the House, the Select Committee or those who work in the Health Service can have of judging the performance, the success or otherwise, of this further reorganisation of the Health Service—a reorganisation brought about only by the desire to clear up some of the mess made by the former Secretary of State, the right hon. Member for Leeds, North-East (Sir K. Joseph), when he guided the last reorganisation Bill through the House in 1971–72.
§ Sir George Young
I hope that I can reply briefly and positively to the points that have just been made.
The purpose of amendment No. 28 is to lay a duty on the Secretary of State to report to Parliament annually for each of the four financial years 1980–81 to 1983–84 on the costs, savings and numbers of jobs dispensed with as a result of establishing district health authorities under clause 1. We propose to make available—although in a slightly different and, I believe, more helpful form—the information that the hon. Gentleman has asked for in his amendment.
We expect to measure savings in management costs through the statutory accounts, but these will not always be available within three months of the end of the financial year, as set out in the amendment, and it would be imprac- 200 tical to insist on that time scale. But, much more important, some—perhaps the majority—of the savings will be achieved not by structural change, under clause 1, but by the review of management arrangements, which is not founded on clause 1. In practice, it will not be easy to attribute a particular saving specifically to structural change as opposed to management arrangements.
Our intention, therefore, is to record savings as one figure per region, aggregating those attributable to both heads. I think that is logical. Part of our strategy requires legislation and part of it does not. It seems sensible to present the consequences of the strategy as one coherent whole rather than to divide it up in the way which the amendment suggests. Therefore, information on costs, savings and manpower reductions will be available, and we have just approved a review by a joint DHSS/NHS group which will enable management cost information to be collected through the annual statutory accounts.
So we can offer to make available the year-by-year reduction in management costs region by region, as opposed to totally, which is asked for in the amendment. But we cannot do it within three months of the end of the financial year, and we propose to do it without showing separately the reductions due to structural change as opposed to those due to simplification of management arrangements, for the reasons that I have outlined.
The £30 million, which does not arise from the amendment, represents our judgment that by reducing the present bureaucracy, with about 250 teams of officers, to between 150 and 180 teams, and by cutting out unnecessary management posts, we shall save roughly 10 per cent. of the costs of managing the Health Service.
I turn to amendment No. 40—and again I hope that I can give some positive encouragement. This matter is being discussed with the Treasury following the debate in Committee. The assumption behind the amendment is that when area health authorities become split into district health authorities there will be an increase in the amount of inter-authority trading. It goes on to assume that VAT will be levied on such transactions.
201 In fact, the amendment is unnecessary, even assuming that the increase in inter-authority transactions which will flow will attract VAT. The VAT liability of health authorities is one of many factors which are considered when allocating resources to health authorities. Separate legislation is not required to enable such factors to be reflected in the sums allotted to health authorities. However, it would be quite wrong if decisions on the best working arrangements within the new structure were to be distorted by the impact of VAT on one form of arrangements and not on another. We shall takes steps to ensure that there is no such distortion, and should it involve more compensation for increased VAT being put back into the Health Service we shall do that.
I hope that in response to those points the hon. Gentleman will feel that he can seek to withdraw the amendment.
§ Mr. Rooker
On the basis of what the Minister has said, which was far more forthcoming than what was said in Committee, I beg to ask leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.